Healthcare Provider Details

I. General information

NPI: 1003631433
Provider Name (Legal Business Name): FRED JOSEPH DURHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2024
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26650 EUREKA RD STE A
TAYLOR MI
48180-4835
US

IV. Provider business mailing address

50216 PAINE ST
CANTON MI
48188-3332
US

V. Phone/Fax

Practice location:
  • Phone: 313-561-5100
  • Fax:
Mailing address:
  • Phone: 765-431-0547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number6851118945
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: