MEDICARE: MICHIGAN MODERN PSYCHOLOGY GROUP,PLLC

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

General Provider Information

NPI Number	:	1447701255
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHIGAN MODERN PSYCHOLOGY GROUP,PLLC

Provider Business Mailing Address
First Line	:	835 MASON ST
Second Line	:	SUITE B 220
City	:	DEARBORN
State	:	MI
Zip	:	48124-2231
Country	:	US
Telephone Number	:	313-561-9064
Fax Number	:	313-563-4480

Provider Business Practice Location Address
First Line	:	835 MASON ST
Second Line	:	SUITE B 220
City	:	DEARBORN
State	:	MI
Zip	:	48124-2231
Country	:	US
Telephone Number	:	313-561-9064
Fax Number	:	313-563-4480

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. MANUEL A MANRIQUE
Credential	:	PHD
Telephone Number	:	313-561-9064

Provider Enumeration Date	:	10/17/2016
Last Update Date	:	05/29/2024

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