Healthcare Provider Details

I. General information

NPI: 1851865968
Provider Name (Legal Business Name): CIRCLE OF LIFE PSYCHOLOGICAL SERVICES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2019
Last Update Date: 01/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 W BIG BEAVER RD STE 200
TROY MI
48084-3524
US

IV. Provider business mailing address

150 LANGE DR
TROY MI
48098-4667
US

V. Phone/Fax

Practice location:
  • Phone: 248-420-6742
  • Fax: 248-243-8668
Mailing address:
  • Phone: 248-420-6742
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARIANNE M. KEY-CARNIAK
Title or Position: OWNER
Credential: MS, LLP, LLMFT
Phone: 248-420-6742