Healthcare Provider Details

I. General information

NPI: 1346738770
Provider Name (Legal Business Name): IDENTITY COUNSELING PSYCHOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2018
Last Update Date: 08/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2350 WASHTENAW AVE STE 4
ANN ARBOR MI
48104
US

IV. Provider business mailing address

2350 WASHTENAW AVE STE 4
ANN ARBOR MI
48104-4525
US

V. Phone/Fax

Practice location:
  • Phone: 734-645-8944
  • Fax: 734-645-8944
Mailing address:
  • Phone: 734-645-8944
  • Fax: 734-645-8944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: TIMOTHY WILKINS
Title or Position: LPC
Credential:
Phone: 734-645-8944