Healthcare Provider Details

I. General information

NPI: 1598326738
Provider Name (Legal Business Name): SPECTRUM SOCIAL COMMUNICATION & COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2019
Last Update Date: 06/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 OAKWOOD DR STE 112
ROCHESTER HILLS MI
48307-6206
US

IV. Provider business mailing address

805 OAKWOOD DR STE 112
ROCHESTER HILLS MI
48307-6206
US

V. Phone/Fax

Practice location:
  • Phone: 248-505-6133
  • Fax:
Mailing address:
  • Phone: 248-505-6133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: TRACY BULLOCK
Title or Position: OWNER / LMSW
Credential:
Phone: 248-505-5043