MEDICARE: DEETRA AMHOWITZ MA, TLLP

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	6301013011	MI

General Provider Information

NPI Number	:	1497762512
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEETRA AMHOWITZ MA, TLLP

Provider Business Mailing Address
First Line	:	43996 WOODWARD AVE STE 101
Second Line	:
City	:	BLOOMFIELD HILLS
State	:	MI
Zip	:	48302-5028
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	43996 WOODWARD AVE STE 101
Second Line	:
City	:	BLOOMFIELD HILLS
State	:	MI
Zip	:	48302-5028
Country	:	US
Telephone Number	:	248-338-2988
Fax Number	:

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

Provider Enumeration Date	:	08/02/2006
Last Update Date	:	07/08/2007

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