Healthcare Provider Details

I. General information

NPI: 1639581044
Provider Name (Legal Business Name): MELANIE VIERECK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2014
Last Update Date: 11/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16200 19 MILE RD
CLINTON TOWNSHIP MI
48038-1103
US

IV. Provider business mailing address

21707 W 14 MILE RD
BEVERLY HILLS MI
48025-2659
US

V. Phone/Fax

Practice location:
  • Phone: 586-263-8700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301015891
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: