Healthcare Provider Details

I. General information

NPI: 1528477908
Provider Name (Legal Business Name): JUAN RAFAEL ZAVALA LLP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2014
Last Update Date: 06/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 W ALEXANDRINE ST
DETROIT MI
48201
US

IV. Provider business mailing address

79 W ALEXANDRINE ST
DETROIT MI
48201-2015
US

V. Phone/Fax

Practice location:
  • Phone: 313-831-5535
  • Fax: 313-831-2608
Mailing address:
  • Phone: 313-831-5535
  • Fax: 313-831-2608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301014144
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: