Healthcare Provider Details

I. General information

NPI: 1598794653
Provider Name (Legal Business Name): BRETT D LINCOLN EDD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

724 BAYBERRY LN
OTSEGO MI
49078-1569
US

IV. Provider business mailing address

724 BAYBERRY LN
OTSEGO MI
49078-1569
US

V. Phone/Fax

Practice location:
  • Phone: 269-823-4328
  • Fax:
Mailing address:
  • Phone: 269-823-4328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301004033
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: