1649561846 NPI number — MICHIGAN HEALTH PSYCHOLOGISTS PLLC

Table of content: (NPI 1649561846)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649561846 NPI number — MICHIGAN HEALTH PSYCHOLOGISTS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHIGAN HEALTH PSYCHOLOGISTS PLLC
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:
1649561846
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/10/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6052
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLYMOUTH
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48170-0052
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-458-1750
Provider Business Mailing Address Fax Number:
248-849-3460

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
199 N MAIN ST STE 106
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLYMOUTH
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48170-1286
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-961-4591
Provider Business Practice Location Address Fax Number:
734-468-1141
Provider Enumeration Date:
04/22/2011

Additional Information

Authorized Official

Authorized Official Last Name:
SYTNIAK
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
B
Authorized Official Title or Position:
PSYCHOLOGIST / OWNER
Authorized Official Telephone Number:
734-458-1750

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  6301008904 , 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)





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