Healthcare Provider Details

I. General information

NPI: 1629639190
Provider Name (Legal Business Name): PATHWAY PSYCHOLOGICAL SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2019
Last Update Date: 06/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22750 WOODWARD AVE STE 211
FERNDALE MI
48220-1753
US

IV. Provider business mailing address

1683 RIVERSIDE DR APT 2
ROCHESTER HILLS MI
48309-2708
US

V. Phone/Fax

Practice location:
  • Phone: 810-333-1386
  • Fax:
Mailing address:
  • Phone: 810-333-1386
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. BRIAN D WUMMEL
Title or Position: OWNER AND COUNSELOR
Credential: PH.D., LPC
Phone: 810-333-1386