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General NPI Number Information
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NPI Number | 1033924071
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Entity Type | Individual
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Provider Name | BYRON C. DOUGLAS PHD
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Gender | Male
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Dates
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Enumeration Date | 02/07/2025
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Last Update Date | 02/07/2025
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Provider Practice Location Address
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Address Line | 2512 HARTE DR
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City | BRIGHTON
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State | MI
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Zip | 48114-7002
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Country | US
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Telephone | 248-761-0998
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Fax |
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Provider Business Mailing Address
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Address Line | 8553 WINDSOR CT
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City | YPSILANTI
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State | MI
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Zip | 48198-3613
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Country | US
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Telephone | 313-910-8473
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 6301006483
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 6301006483
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License Number State | MI
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Taxonomy #3
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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