MEDICARE: PERFORMANCE 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	251S00000X	Community/Behavioral Health Agency	6301009306	MI

General Provider Information

NPI Number	:	1891950895
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERFORMANCE PSYCHOLOGY

Provider Business Mailing Address
First Line	:	9287 SILVERSIDE
Second Line	:
City	:	SOUTH LYON
State	:	MI
Zip	:	48178-9316
Country	:	US
Telephone Number	:	586-764-0637
Fax Number	:	810-695-0343

Provider Business Practice Location Address
First Line	:	9287 SILVERSIDE
Second Line	:
City	:	SOUTH LYON
State	:	MI
Zip	:	48178-9316
Country	:	US
Telephone Number	:	586-764-0637
Fax Number	:	810-695-0343

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. TODD JOHN NADEAU
Credential	:	M.A., LLP
Telephone Number	:	586-764-0637

Provider Enumeration Date	:	07/20/2008
Last Update Date	:	07/20/2008

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Directions to “PERFORMANCE PSYCHOLOGY ” Practice Location

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