Healthcare Provider Details

I. General information

NPI: 1487164034
Provider Name (Legal Business Name): JUANITA HOUSTON TLLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2017
Last Update Date: 10/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34841 VETERANS PLZ
WAYNE MI
48184-1733
US

IV. Provider business mailing address

14271 STEEL ST
DETROIT MI
48227-3939
US

V. Phone/Fax

Practice location:
  • Phone: 313-292-7640
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301016691
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: