Healthcare Provider Details

I. General information

NPI: 1700790771
Provider Name (Legal Business Name): MADELEINE REARDON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 CHRYSLER DR
DETROIT MI
48201-2167
US

IV. Provider business mailing address

7043 CHIRCO DR
SHELBY TWP MI
48316-3423
US

V. Phone/Fax

Practice location:
  • Phone: 586-703-6250
  • Fax:
Mailing address:
  • Phone: 586-703-6250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6362010145
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: