Healthcare Provider Details

I. General information

NPI: 1073161907
Provider Name (Legal Business Name): PEDIATRIC AND ADOLESCENT BEHAVIORAL COUNSELING, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2019
Last Update Date: 11/13/2022
Certification Date: 11/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36400 WOODWARD AVE STE 110
BLOOMFIELD HILLS MI
48304-0912
US

IV. Provider business mailing address

36400 WOODWARD AVE STE 110
BLOOMFIELD HILLS MI
48304-0912
US

V. Phone/Fax

Practice location:
  • Phone: 248-973-7958
  • Fax: 972-323-7684
Mailing address:
  • Phone: 248-973-7958
  • Fax: 972-323-7684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DENNIELLE MCIVER
Title or Position: OWNER
Credential: MS LPC NCC CCTP
Phone: 248-973-7958