Healthcare Provider Details

I. General information

NPI: 1003244732
Provider Name (Legal Business Name): PATRICIA COMPOS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2013
Last Update Date: 10/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2514 BIDDLE AVE
WYANDOTTE MI
48192-7891
US

IV. Provider business mailing address

20678 MERIDIAN RD
GROSSE ILE MI
48138-1278
US

V. Phone/Fax

Practice location:
  • Phone: 734-558-8643
  • Fax:
Mailing address:
  • Phone: 734-558-8643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number6301012050
License Number StateMI

VIII. Authorized Official

Name: DR. PATRICIA L COMPOS
Title or Position: OPWNER/PSYCHOLOGIST
Credential: PH.D.
Phone: 734-558-8643