=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902162746
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DELTA FAMILY CLINIC SOUTH PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2012
-----------------------------------------------------
Last Update Date | 04/05/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 901 N. EUCLID AVE.
-----------------------------------------------------
City | BAY CITY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-671-9798
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6195 MILLER RD. STE. A
-----------------------------------------------------
City | SWARTZ CREEK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48473
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-630-1152
-----------------------------------------------------
Fax | 810-630-9107
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO/ ADNIMISTRATOR
-----------------------------------------------------
Name | GERARD WILLIAMS
-----------------------------------------------------
Credential | PH.D
-----------------------------------------------------
Telephone | 810-630-1152
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------