=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700423092
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEVIKA DIBYA CHOUDHURI PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2019
-----------------------------------------------------
Last Update Date | 12/05/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 135 PORTER WEST CIRCLE DRIVE
-----------------------------------------------------
City | YPSILANTI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48197
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-487-4410
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 304 PORTER WEST CIRCLE DRIVE
-----------------------------------------------------
City | YPSILANTI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48197
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-487-2756
-----------------------------------------------------
Fax | 734-487-4608
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 6401008079
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 002648
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------