MEDICARE: DR. MELISSA RENEE BOGDALEK PSYD, LLP

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	6361008099	MI

General Provider Information

NPI Number	:	1992269633
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MELISSA RENEE BOGDALEK PSYD, LLP

Provider Business Mailing Address
First Line	:	100 N POND DR STE A
Second Line	:
City	:	WALLED LAKE
State	:	MI
Zip	:	48390-3079
Country	:	US
Telephone Number	:	248-755-5874
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 N POND DR STE A
Second Line	:
City	:	WALLED LAKE
State	:	MI
Zip	:	48390-3079
Country	:	US
Telephone Number	:	248-755-5874
Fax Number	:	866-607-5280

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

Provider Enumeration Date	:	01/28/2019
Last Update Date	:	12/04/2025

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