MEDICARE: DR. KYLE ALAN GLASGOW PSYD, LP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	6301012482	MI
2	103TA0700X	Adult Development & Aging Psychologist	6301012482	MI
3	103TC0700X	Clinical Psychologist	6301012482	MI

General Provider Information

NPI Number	:	1114175148
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KYLE ALAN GLASGOW PSYD, LP

Provider Business Mailing Address
First Line	:	26105 ORCHARD LAKE RD
Second Line	:	STE 204
City	:	FARMINGTON HILLS
State	:	MI
Zip	:	48334-4576
Country	:	US
Telephone Number	:	313-296-1779
Fax Number	:	248-957-8544

Provider Business Practice Location Address
First Line	:	26105 ORCHARD LAKE RD
Second Line	:	STE 204
City	:	FARMINGTON HILLS
State	:	MI
Zip	:	48334-4576
Country	:	US
Telephone Number	:	313-296-1779
Fax Number	:	248-957-8544

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/03/2008
Last Update Date	:	08/29/2015

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