MEDICARE: JOHN H TRASK PH.D.

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	103TC0700X	Clinical Psychologist	6301007751	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1164693362	OTHER		NPPES
2	68-0-F3-2859-0	OTHER	MI	BLUE CROSS BLUE SHIELD MI

General Provider Information

NPI Number	:	1417924200
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN H TRASK PH.D.

Provider Business Mailing Address
First Line	:	200 E BIG BEAVER RD
Second Line	:
City	:	TROY
State	:	MI
Zip	:	48083-1208
Country	:	US
Telephone Number	:	248-689-4600
Fax Number	:	248-519-1201

Provider Business Practice Location Address
First Line	:	650 E BIG BEAVER RD
Second Line	:	SUITE A
City	:	TROY
State	:	MI
Zip	:	48083-1432
Country	:	US
Telephone Number	:	248-689-4600
Fax Number	:	248-519-1201

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

Provider Enumeration Date	:	03/01/2006
Last Update Date	:	01/13/2021

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