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General NPI Number Information
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NPI Number | 1255953162
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Entity Type | Organization
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Legal Business Name | 360 PSYCHOTHERAPY AND CONSULTING PLLC
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Dates
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Enumeration Date | 05/13/2020
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Last Update Date | 05/13/2020
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Provider Practice Location Address
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Address Line | 777 LIVERNOIS ST
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City | FERNDALE
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State | MI
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Zip | 48220-2306
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Country | US
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Telephone | 248-770-6339
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Fax |
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Provider Business Mailing Address
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Address Line | 777 LIVERNOIS ST
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City | FERNDALE
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State | MI
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Zip | 48220-2306
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Country | US
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Telephone | 248-770-6339
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Fax |
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Authorized Official
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Title or Position | OWNER/CLINICAL PSYCHOLOGIST
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Name | DR. CARRIE NANTAIS
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Credential | PH.D.
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Telephone | 248-770-6339
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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