Healthcare Provider Details

I. General information

NPI: 1104071927
Provider Name (Legal Business Name): ELLEN MAYFIELD-FLEMING MALLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2008
Last Update Date: 11/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42669 GARFIELD RD
CLINTON TWP MI
48038-5036
US

IV. Provider business mailing address

12850 FOUNTAIN SQ
DAVISBURG MI
48350-2552
US

V. Phone/Fax

Practice location:
  • Phone: 586-412-5321
  • Fax:
Mailing address:
  • Phone: 248-634-6303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301010626
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: