=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215928643
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPECTRUM REHABILITATION CENTERS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2005
-----------------------------------------------------
Last Update Date | 05/24/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 26555 EVERGREEN RD STE 830
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48076-4206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-350-3650
-----------------------------------------------------
Fax | 248-350-1216
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 26555 EVERGREEN RD STE 830
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48076-4206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-350-3650
-----------------------------------------------------
Fax | 248-350-1216
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. BRADLEY G SEWICK
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 248-350-3650
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number | 6301005256
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------