1750087425 NPI number — DMG PSYCHOLOGY

Table of content: (NPI 1750087425)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750087425 NPI number — DMG PSYCHOLOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DMG PSYCHOLOGY
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:
REGULATING RESOLUTIONS
Provider Other Organization Name Type Code:
5
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:
1750087425
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/10/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3070 LINDENWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DEARBORN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48120-1312
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-528-9146
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23400 PARK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEARBORN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48124-2545
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-528-9146
Provider Business Practice Location Address Fax Number:
313-558-8384
Provider Enumeration Date:
02/06/2023

Additional Information

Authorized Official

Authorized Official Last Name:
GOETSCH
Authorized Official First Name:
DIANNE
Authorized Official Middle Name:
Authorized Official Title or Position:
MASTER'S LICENSED PSYCHOLOGIST
Authorized Official Telephone Number:
313-528-9146

Provider Taxonomy Codes

  • 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: "Y" .

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

  • Identifier: 12754218 . This is a "CAQH" identifier . This identifiers is of the category "OTHER".




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