=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023059789
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARC J SILVERSTONE PHD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2006
-----------------------------------------------------
Last Update Date | 02/23/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6149 N WAYNE RD
-----------------------------------------------------
City | WESTLAND
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48185-7128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-728-2130
-----------------------------------------------------
Fax | 734-728-2626
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4750 HARDWOODS DR
-----------------------------------------------------
City | WEST BLOOMFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48323-2636
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-728-2130
-----------------------------------------------------
Fax | 734-728-2626
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | MS063878
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------