Healthcare Provider Details

I. General information

NPI: 1871560326
Provider Name (Legal Business Name): MARTIN GERARD WUNSCH PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2006
Last Update Date: 02/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43211 DALCOMA DR SUITE 11
CLINTON TOWNSHIP MI
48038-6309
US

IV. Provider business mailing address

1728 BRENTWOOD DR
TROY MI
48098-2630
US

V. Phone/Fax

Practice location:
  • Phone: 586-263-0947
  • Fax: 248-267-5899
Mailing address:
  • Phone: 586-263-0947
  • Fax: 248-267-5899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number6301005658
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301005658
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301005658
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: