Healthcare Provider Details

I. General information

NPI: 1205134525
Provider Name (Legal Business Name): MICHIGAN BEHAVIORAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2011
Last Update Date: 06/28/2021
Certification Date: 06/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 CROOKS RD STE 100
TROY MI
48084-4733
US

IV. Provider business mailing address

2525 CROOKS RD STE 100
TROY MI
48084-4733
US

V. Phone/Fax

Practice location:
  • Phone: 248-731-7305
  • Fax: 248-731-7288
Mailing address:
  • Phone: 248-731-7305
  • Fax: 248-731-7288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateMI

VIII. Authorized Official

Name: MS. RENE JOSEPH
Title or Position: ADMINISTRATOR
Credential:
Phone: 248-703-1897