Healthcare Provider Details

I. General information

NPI: 1831265396
Provider Name (Legal Business Name): JOSEPH CHARLES MIFSUD MA, LLP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20811 KELLY RD # 103
EASTPOINTE MI
48021-3139
US

IV. Provider business mailing address

28000 DEQUINDRE RD
WARREN MI
48092-2468
US

V. Phone/Fax

Practice location:
  • Phone: 586-445-2210
  • Fax: 586-445-0700
Mailing address:
  • Phone: 586-753-0405
  • Fax: 586-753-0404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301012406
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: