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General NPI Number Information
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NPI Number | 1447701255
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Entity Type | Organization
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Legal Business Name | MICHIGAN MODERN PSYCHOLOGY GROUP,PLLC
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Dates
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Enumeration Date | 10/17/2016
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Last Update Date | 05/29/2024
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Provider Practice Location Address
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Address Line | 835 MASON ST SUITE B 220
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City | DEARBORN
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State | MI
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Zip | 48124-2231
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Country | US
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Telephone | 313-561-9064
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Fax | 313-563-4480
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Provider Business Mailing Address
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Address Line | 835 MASON ST SUITE B 220
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City | DEARBORN
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State | MI
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Zip | 48124-2231
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Country | US
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Telephone | 313-561-9064
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Fax | 313-563-4480
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Authorized Official
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Title or Position | DIRECTOR
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Name | DR. MANUEL A MANRIQUE
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Credential | PHD
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Telephone | 313-561-9064
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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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