Healthcare Provider Details

I. General information

NPI: 1134384274
Provider Name (Legal Business Name): ROSALYNN MARIE MOTEN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2008
Last Update Date: 11/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 GOLFVIEW DR APT 202
TROY MI
48084-3919
US

IV. Provider business mailing address

2215 GOLFVIEW DR APT 202
TROY MI
48084-3919
US

V. Phone/Fax

Practice location:
  • Phone: 313-719-1649
  • Fax: 248-792-3042
Mailing address:
  • Phone: 313-719-1649
  • Fax: 248-792-3042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301011759
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number6301011759
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: