MEDICARE: VIA VIRTUS CLINICAL PSYCHOLOGY SERVICES

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1205789195
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VIA VIRTUS CLINICAL PSYCHOLOGY SERVICES

Provider Business Mailing Address
First Line	:	884 S ROCHESTER RD
Second Line	:
City	:	ROCHESTER HILLS
State	:	MI
Zip	:	48307-2740
Country	:	US
Telephone Number	:	248-784-4374
Fax Number	:

Provider Business Practice Location Address
First Line	:	884 S ROCHESTER RD
Second Line	:
City	:	ROCHESTER HILLS
State	:	MI
Zip	:	48307-2740
Country	:	US
Telephone Number	:	248-784-4374
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	CASSIDY AZZOW
Credential	:
Telephone Number	:	248-784-4374

Provider Enumeration Date	:	02/19/2026
Last Update Date	:	02/19/2026

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