MEDICARE: DMG PSYCHOLOGY

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	103T00000X	Psychologist
2	103TC0700X	Clinical Psychologist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	12754218	OTHER		CAQH

General Provider Information

NPI Number	:	1750087425
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DMG PSYCHOLOGY

Provider Business Mailing Address
First Line	:	18518 OUTER DR
Second Line	:
City	:	DEARBORN
State	:	MI
Zip	:	48128-1874
Country	:	US
Telephone Number	:	313-528-9146
Fax Number	:

Provider Business Practice Location Address
First Line	:	18518 OUTER DR
Second Line	:
City	:	DEARBORN
State	:	MI
Zip	:	48128-1874
Country	:	US
Telephone Number	:	313-288-2450
Fax Number	:

Authorized Official
Title or Position	:	MASTER'S LICENSED PSYCHOLOGIST
Name	:	DIANNE GOETSCH
Credential	:	MS, LLP
Telephone Number	:	313-528-9146

Provider Enumeration Date	:	02/06/2023
Last Update Date	:	08/22/2025

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