Healthcare Provider Details

I. General information

NPI: 1346755345
Provider Name (Legal Business Name): CHRISTINA SIDERS WESLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2017
Last Update Date: 12/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 N CENTER ST
NORTHVILLE MI
48167-1277
US

IV. Provider business mailing address

7448 N LAFAYETTE ST
DEARBORN HEIGHTS MI
48127-1759
US

V. Phone/Fax

Practice location:
  • Phone: 313-656-4052
  • Fax:
Mailing address:
  • Phone: 248-890-1025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301017325
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: