=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336969617
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GT PSYCHIATRIC SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2024
-----------------------------------------------------
Last Update Date | 10/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29532 SOUTHFIELD RD STE 115
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48076-2023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-724-5341
-----------------------------------------------------
Fax | 734-506-1647
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 702097
-----------------------------------------------------
City | PLYMOUTH
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48170-0975
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-724-5341
-----------------------------------------------------
Fax | 734-506-1647
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER
-----------------------------------------------------
Name | DR. BRANDON MOORE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 734-724-5341
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------