Healthcare Provider Details

I. General information

NPI: 1588991251
Provider Name (Legal Business Name): REBECCA VLASIC MA LLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2009
Last Update Date: 11/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20300 CIVIC CENTER DR
SOUTHFIELD MI
48076-4105
US

IV. Provider business mailing address

1870 REDDING RD
BIRMINGHAM MI
48009-1054
US

V. Phone/Fax

Practice location:
  • Phone: 248-559-8190
  • Fax: 248-559-8776
Mailing address:
  • Phone: 248-535-0345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301008441
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: