1073647731 NPI number — BURDETTE AND DOSS PSYCHOLOGICAL SERVICES LC

Table of Contents

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: 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: 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: 261QR0405X , with the licence number: 630534 , registered in the state of MI ; 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: 101YP2500X ; 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" .

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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