=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689100729
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PARKER CLINIC PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2017
-----------------------------------------------------
Last Update Date | 05/11/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 43902 WOODWARD AVE STE 110
-----------------------------------------------------
City | BLOOMFIELD HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48302-5021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-338-1700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 43902 WOODWARD AVE STE 110
-----------------------------------------------------
City | BLOOMFIELD HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48302-5021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-338-1700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MITCHELL S PARKER
-----------------------------------------------------
Credential | LP
-----------------------------------------------------
Telephone | 248-338-1700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 6301011448
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------