Healthcare Provider Details

I. General information

NPI: 1154391449
Provider Name (Legal Business Name): CHAD E MUFFLEY MA LLP
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5220 LOVERS LANE SUITE 120
PORTAGE MI
49002
US

IV. Provider business mailing address

5220 LOVERS LANE SUITE 120
PORTAGE MI
49002
US

V. Phone/Fax

Practice location:
  • Phone: 269-344-3080
  • Fax: 269-344-0543
Mailing address:
  • Phone: 269-344-3080
  • Fax: 269-344-0543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number6301011598
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: