Healthcare Provider Details

I. General information

NPI: 1982029179
Provider Name (Legal Business Name): DANIEL DREVON PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2014
Last Update Date: 09/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 HEALTH PROFESSIONS BLDG
MT PLEASANT MI
48859-0001
US

IV. Provider business mailing address

1101 HEALTH PROFESSIONS BLDG
MT PLEASANT MI
48859-0001
US

V. Phone/Fax

Practice location:
  • Phone: 989-774-3904
  • Fax: 989-774-1891
Mailing address:
  • Phone: 989-774-3904
  • Fax: 989-774-1891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number6301015682
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number6301015682
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: