Healthcare Provider Details

I. General information

NPI: 1699516583
Provider Name (Legal Business Name): COREY D HOLDEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2024
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13101 ALLEN RD
SOUTHGATE MI
48195-2216
US

IV. Provider business mailing address

23217 RUSSELL ST
SOUTHFIELD MI
48075-7818
US

V. Phone/Fax

Practice location:
  • Phone: 734-785-7700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6362009571
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: