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NPI Code Detail

MEDICARE: BEACON PSYCHOLOGICAL SERVICES

MEDICARE: BEACON PSYCHOLOGICAL 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
1103T00000XPsychologist

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1NAOTHERNA

General Provider Information

NPI Number : 1255990685
Entity Type Code : Organization
Provider Name (Legal Business Name) : BEACON PSYCHOLOGICAL SERVICES
Provider Business Mailing Address
First Line : 195 SHINNECOCK DR
Second Line :
City : BRIGHTON
State : MI
Zip : 48114-8832
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 33150 SCHOOLCRAFT RD STE L03
Second Line :
City : LIVONIA
State : MI
Zip : 48150-1631
Country : US
Telephone Number : 248-497-3411
Fax Number :
Authorized Official
Title or Position : LIMITED LICENSED PSYCHOLOGIST
Name : KATHRYN STARON
Credential :
Telephone Number : 248-497-3411
Provider Enumeration Date : 06/10/2019
Last Update Date : 06/10/2019

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