MEDICARE: DR. JEFFREY SCOTT DEGROAT 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	012619	MI

General Provider Information

NPI Number	:	1912946971
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY SCOTT DEGROAT PH.D.

Provider Business Mailing Address
First Line	:	19900 E 10 MILE RD
Second Line	:	SUITE 102
City	:	SAINT CLAIR SHORES
State	:	MI
Zip	:	48080-4412
Country	:	US
Telephone Number	:	586-776-3366
Fax Number	:	586-776-3369

Provider Business Practice Location Address
First Line	:	19900 E 10 MILE RD
Second Line	:	SUITE 102
City	:	SAINT CLAIR SHORES
State	:	MI
Zip	:	48080-4412
Country	:	US
Telephone Number	:	586-776-3366
Fax Number	:	586-776-3369

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

Provider Enumeration Date	:	06/05/2006
Last Update Date	:	05/09/2013

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