MEDICARE: DR. EMANUEL T VANBOLDEN PHD LP

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	6301011393	MI
2	103TC0700X	Clinical Psychologist	6301013909	MI

General Provider Information

NPI Number	:	1952500621
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EMANUEL T VANBOLDEN PHD LP

Provider Business Mailing Address
First Line	:	42335 WOODWARD AVE
Second Line	:
City	:	BLOOMFIELD HILLS
State	:	MI
Zip	:	48304-5040
Country	:	US
Telephone Number	:	248-333-1083
Fax Number	:

Provider Business Practice Location Address
First Line	:	42335 WOODWARD AVE
Second Line	:
City	:	BLOOMFIELD HILLS
State	:	MI
Zip	:	48304-5040
Country	:	US
Telephone Number	:	248-333-1083
Fax Number	:

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

Provider Enumeration Date	:	07/13/2007
Last Update Date	:	05/15/2024

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