Healthcare Provider Details

I. General information

NPI: 1265603716
Provider Name (Legal Business Name): WILLIAM C IRVING PHD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2008
Last Update Date: 01/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22811 GREATER MACK AVE SUITE 202
SAINT CLAIR SHORES MI
48080-2021
US

IV. Provider business mailing address

22811 GREATER MACK AVE SUITE 202
SAINT CLAIR SHORES MI
48080-2021
US

V. Phone/Fax

Practice location:
  • Phone: 586-443-4402
  • Fax: 586-443-4412
Mailing address:
  • Phone: 586-443-4402
  • Fax: 586-443-4412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MS. JUDY I.
Title or Position: OFFICE MANAGER
Credential:
Phone: 586-443-4402