Healthcare Provider Details

I. General information

NPI: 1316119498
Provider Name (Legal Business Name): MHSDD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2008
Last Update Date: 04/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33000 ANNAPOLIS ST SUITE 150
WAYNE MI
48184-2917
US

IV. Provider business mailing address

PO BOX 44047
DETROIT MI
48244-0047
US

V. Phone/Fax

Practice location:
  • Phone: 734-728-3446
  • Fax: 734-728-4893
Mailing address:
  • Phone: 248-543-8070
  • Fax: 248-543-9005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. OLIN KEITH LEPARD
Title or Position: MANAGER
Credential: MD
Phone: 248-543-8070