=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700159670
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEIDI BAIRD MARTIN PSYD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2012
-----------------------------------------------------
Last Update Date | 02/23/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 676 SMITH AVE
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48009-2029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-497-5166
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 676 SMITH AVE
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48009-2029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-497-5166
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TB0200X
-----------------------------------------------------
Taxonomy Name | Cognitive & Behavioral Psychologist
-----------------------------------------------------
License Number | 6301012698
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 6301012698
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103TH0004X
-----------------------------------------------------
Taxonomy Name | Health Psychologist
-----------------------------------------------------
License Number | 6301012698
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 103TH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Psychologist
-----------------------------------------------------
License Number | 6301012698
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 103TP2701X
-----------------------------------------------------
Taxonomy Name | Group Psychotherapy Psychologist
-----------------------------------------------------
License Number | 6301012698
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 103TR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Psychologist
-----------------------------------------------------
License Number | 6301012698
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 6301012698
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------