Healthcare Provider Details

I. General information

NPI: 1750894515
Provider Name (Legal Business Name): IAN GOLDSBROUGH MS, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2017
Last Update Date: 07/16/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24715 LITTLE MACK AVE STE 200
SAINT CLAIR SHORES MI
48080-3207
US

IV. Provider business mailing address

24715 LITTLE MACK AVE STE 200
SAINT CLAIR SHORES MI
48080-3207
US

V. Phone/Fax

Practice location:
  • Phone: 517-882-3732
  • Fax: 517-882-3633
Mailing address:
  • Phone: 517-882-3732
  • Fax: 517-882-3633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401018782
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: