Healthcare Provider Details

I. General information

NPI: 1568110898
Provider Name (Legal Business Name): PATOOL MAKKI MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2022
Last Update Date: 12/23/2024
Certification Date: 12/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4520 FIRESTONE ST
DEARBORN MI
48126-4602
US

IV. Provider business mailing address

4520 FIRESTONE ST
DEARBORN MI
48126-4602
US

V. Phone/Fax

Practice location:
  • Phone: 313-470-1860
  • Fax:
Mailing address:
  • Phone: 313-470-1860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number636201001
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: