Healthcare Provider Details

I. General information

NPI: 1669715637
Provider Name (Legal Business Name): JAY STEPHEN WITHERELL PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2013
Last Update Date: 03/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8303 PLATT RD
SALINE MI
48176-9773
US

IV. Provider business mailing address

41740 W VILLAGE GREEN BLVD APT. 204
CANTON MI
48187-5318
US

V. Phone/Fax

Practice location:
  • Phone: 734-429-2531
  • Fax:
Mailing address:
  • Phone: 419-349-1050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301015464
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: