1073647731 NPI number — BURDETTE AND DOSS PSYCHOLOGICAL SERVICES LC

Table of content: (NPI 1073647731)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073647731 NPI number — BURDETTE AND DOSS PSYCHOLOGICAL SERVICES LC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BURDETTE AND DOSS PSYCHOLOGICAL SERVICES LC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073647731
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/28/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17352 W 12 MILE RD
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
SOUTHFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48076-2119
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-559-0730
Provider Business Mailing Address Fax Number:
248-569-7626

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17352 W 12 MILE RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
SOUTHFIELD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48076-2119
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-559-0730
Provider Business Practice Location Address Fax Number:
248-569-7626
Provider Enumeration Date:
03/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TYSELL
Authorized Official First Name:
BARBARA ANN
Authorized Official Middle Name:
ELISABETH
Authorized Official Title or Position:
ADMINISTRATIVE DIRECTOR
Authorized Official Telephone Number:
248-559-0730

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC2200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TP0814X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0801X , with the licence number: 630534 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QR0405X , with the licence number: 630534 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 750910921 . This is a "BCBS TRADITIONAL CODE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 20700 . This is a "BCBS SUB AB AND MGD CARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 7509109210 . This is a "BCBS NASCO IDENTIFIER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1316097488 . This is a "NPPESJAMES A. COWLEY NPI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 26 0 F3 2684 0 . This is a "NASCO GROUP TRACKING ID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 38314498 . This is a "HAP PROVIDER ID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 7509109210 . This is a "VALUEOPTIONS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0911921 . This is a "BCBS PROVIDER ID MDS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0913921 . This is a "BCBS PROVIDER ID MASTERS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 630534 . This is a "STATE SUBSTANCE ABUSE LIC" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0912921 . This is a "BCBS PROVIDER ID PHDS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 10921 . This is a "BCBS MANAGED CARE CODE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: F037350 . This is a "WEB DENIS IDENTIFIER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 187925000 . This is a "MAGELLAN IDENTIFIER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0910921 . This is a "BCBS OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 125750 . This is a "VALUE OPTIONS PROVIDER ID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P69427 . This is a "BLUE CARE NETWORK PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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