Healthcare Provider Details

I. General information

NPI: 1649617317
Provider Name (Legal Business Name): JOSHUA MACK VINOVA MA, LLP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2013
Last Update Date: 09/05/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8245 HOLLY RD
GRAND BLANC MI
48439-2443
US

IV. Provider business mailing address

1918 GEORGETOWN PKWY
FENTON MI
48430-3223
US

V. Phone/Fax

Practice location:
  • Phone: 800-693-1916
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6361004461
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: