Healthcare Provider Details

I. General information

NPI: 1326267121
Provider Name (Legal Business Name): DAVID H WAXER LLP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 08/06/2022
Certification Date: 08/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20300 CIVIC CENTER DR STE 303 NORTHLAND CLINIC
SOUTHFIELD MI
48076
US

IV. Provider business mailing address

PO BOX 210550
AUBURN HILLS MI
48321-0550
US

V. Phone/Fax

Practice location:
  • Phone: 248-559-8190
  • Fax: 248-559-8776
Mailing address:
  • Phone: 800-693-1916
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number4101006301
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6361004793
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: