=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528831195
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMPASSIONATE COURAGE, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2023
-----------------------------------------------------
Last Update Date | 10/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29777 TELEGRAPH RD STE 2410
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48034-7632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-943-0278
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24605 RIVERWOOD DR
-----------------------------------------------------
City | FRANKLIN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48025-2227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-943-0278
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST
-----------------------------------------------------
Name | DR. CONSTANCE RHODES VICTOR
-----------------------------------------------------
Credential | PSYD
-----------------------------------------------------
Telephone | 248-943-0278
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------