Basic Information
| Provider Information | |||||||||
| NPI: | 1104346402 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANTON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | CHARLES | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PSY.D., LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9919 SHADYSIDE ST | ||||||||
| Address2: | |||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481502715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7348378374 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7800 W OUTER DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482353458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3133404442 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2017 | ||||||||
| LastUpdateDate: | 10/17/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 6301017108 | MI | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103T00000X | 6301017108 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | 101YP2500X | 178.008499 | IL | N | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.