Healthcare Provider Details

I. General information

NPI: 1588266985
Provider Name (Legal Business Name): PSYCH ELEMENTS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2020
Last Update Date: 11/10/2020
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3227 WOODVIEW LAKE RD
WEST BLOOMFIELD MI
48323-3572
US

IV. Provider business mailing address

3227 WOODVIEW LAKE RD
WEST BLOOMFIELD MI
48323-3572
US

V. Phone/Fax

Practice location:
  • Phone: 248-459-6767
  • Fax:
Mailing address:
  • Phone: 248-459-6767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. ELLIE LEDERMAN
Title or Position: OWNER AND LICENSED PSYCHOLOGIST
Credential: PSYD
Phone: 248-459-6767