Healthcare Provider Details

I. General information

NPI: 1609173921
Provider Name (Legal Business Name): GREAT MINDS OF MICHIGAN PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2011
Last Update Date: 02/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 DIVERSION ST SUITE 150
ROCHESTER HILLS MI
48307-2267
US

IV. Provider business mailing address

23210 GREATER MACK AVE #216
SAINT CLAIR SHORES MI
48080-3422
US

V. Phone/Fax

Practice location:
  • Phone: 586-913-1038
  • Fax: 586-773-3355
Mailing address:
  • Phone: 586-913-1038
  • Fax: 586-773-3355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number6301012828
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301012828
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number6301012828
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number6301012828
License Number StateMI

VIII. Authorized Official

Name: DR. JANET S REED
Title or Position: MEMBER, DIRECTOR
Credential: PHD
Phone: 586-913-1038