Healthcare Provider Details

I. General information

NPI: 1154470755
Provider Name (Legal Business Name): ACCESS CHRISTIAN COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 12/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29260 FRANKLIN RD SUITE 121
SOUTHFIELD MI
48034-1161
US

IV. Provider business mailing address

29260 FRANKLIN RD SUITE 121
SOUTHFIELD MI
48034-1161
US

V. Phone/Fax

Practice location:
  • Phone: 248-355-4300
  • Fax: 248-355-4393
Mailing address:
  • Phone: 248-355-4300
  • Fax: 248-355-4393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301012712
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number6301010435
License Number StateMI

VIII. Authorized Official

Name: DR. CHARLES EARNEST CAPICCHIONI
Title or Position: DIRECTOR
Credential: PSY.D., L.L.P.
Phone: 248-355-4300