Healthcare Provider Details

I. General information

NPI: 1669286639
Provider Name (Legal Business Name): COLIN J DUFFY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2025
Last Update Date: 02/01/2025
Certification Date: 02/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15173 NORTH RD STE 100
FENTON MI
48430-1381
US

IV. Provider business mailing address

8490 ALTA VISTA DR
PINCKNEY MI
48169-8480
US

V. Phone/Fax

Practice location:
  • Phone: 810-771-4074
  • Fax:
Mailing address:
  • Phone: 810-626-8882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6451024015
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: