=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093881740
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STONEY CREEK PSYCHOLOGICAL CONSULTING PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/27/2006
-----------------------------------------------------
Last Update Date | 03/04/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 455 BARCLAY CIR STE C1
-----------------------------------------------------
City | ROCHESTER HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48307-4774
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-969-0176
-----------------------------------------------------
Fax | 248-853-0015
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 455 BARCLAY CIR STE C1
-----------------------------------------------------
City | ROCHESTER HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48307-4774
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-969-0176
-----------------------------------------------------
Fax | 248-853-0015
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYCHOLOGIST
-----------------------------------------------------
Name | JANET MCPEEK
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 248-969-0176
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 6301007338
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------