Healthcare Provider Details

I. General information

NPI: 1962920843
Provider Name (Legal Business Name): PAUL TATE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2017
Last Update Date: 06/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15930 19 MILE RD STE 150
CLINTON TOWNSHIP MI
48038
US

IV. Provider business mailing address

15930 19 MILE RD STE 150
CLINTON TOWNSHIP MI
48038-1155
US

V. Phone/Fax

Practice location:
  • Phone: 586-464-0175
  • Fax:
Mailing address:
  • Phone: 586-464-0175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: