Healthcare Provider Details

I. General information

NPI: 1396013017
Provider Name (Legal Business Name): MAVIS EMMA BUZZARD MA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2011
Last Update Date: 05/19/2024
Certification Date: 05/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2609 CROOKS RD
TROY MI
48084-4714
US

IV. Provider business mailing address

1443 N BYWOOD AVE
CLAWSON MI
48017-1101
US

V. Phone/Fax

Practice location:
  • Phone: 248-274-6193
  • Fax:
Mailing address:
  • Phone: 586-354-8858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401012803
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: