Healthcare Provider Details

I. General information

NPI: 1669427639
Provider Name (Legal Business Name): DAVID MITTELMAN PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 04/04/2024
Certification Date: 04/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29551 GREENFIELD RD STE 204
SOUTHFIELD MI
48076-5872
US

IV. Provider business mailing address

29551 GREENFIELD RD STE 204
SOUTHFIELD MI
48076-5872
US

V. Phone/Fax

Practice location:
  • Phone: 248-980-8349
  • Fax: 248-848-3592
Mailing address:
  • Phone: 248-980-8349
  • Fax: 248-848-3592

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number007389
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number007389
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: