=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740356138
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLENE LOUISE MCGUNN PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2006
-----------------------------------------------------
Last Update Date | 10/04/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 DIVERSION ST STE 150
-----------------------------------------------------
City | ROCHESTER HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48307-2207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-370-8164
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 70125
-----------------------------------------------------
City | ROCHESTER HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48307-0003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-370-8164
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 6801015031
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 6301010074
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------