MEDICARE: DENISE G DURAK PSYD

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	6301003189	MI

General Provider Information

NPI Number	:	1134390677
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENISE G DURAK PSYD

Provider Business Mailing Address
First Line	:	7889 RED ARROW HWY
Second Line	:
City	:	STEVENSVILLE
State	:	MI
Zip	:	49127-9999
Country	:	US
Telephone Number	:	269-465-4000
Fax Number	:	269-465-4001

Provider Business Practice Location Address
First Line	:	7889 RED ARROW HWY
Second Line	:
City	:	STEVENSVILLE
State	:	MI
Zip	:	49127-9999
Country	:	US
Telephone Number	:	269-465-4000
Fax Number	:	269-465-4001

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

Provider Enumeration Date	:	03/12/2008
Last Update Date	:	03/12/2008

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