Healthcare Provider Details

I. General information

NPI: 1326393752
Provider Name (Legal Business Name): CLARKSTON FAMILY THERAPISTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2012
Last Update Date: 11/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5639 SASHABAW RD
CLARKSTON MI
48346-3149
US

IV. Provider business mailing address

5639 SASHABAW RD
CLARKSTON MI
48346-3149
US

V. Phone/Fax

Practice location:
  • Phone: 248-922-9077
  • Fax: 248-922-9040
Mailing address:
  • Phone: 248-922-9077
  • Fax: 248-922-9040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateMI

VIII. Authorized Official

Name: DR. FRANCIS M DONNELLY
Title or Position: OWNER
Credential: PHD
Phone: 248-922-9077