=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104066679
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEFFREY DEGROAT PHD PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2009
-----------------------------------------------------
Last Update Date | 02/24/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21929 E 9 MILE RD
-----------------------------------------------------
City | SAINT CLAIR SHORES
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48080-2906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-776-3366
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21929 E 9 MILE RD
-----------------------------------------------------
City | SAINT CLAIR SHORES
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48080-2906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DR. JEFFREY DEGROAT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 586-776-3366
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 6301012619
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------