Basic Information
| Provider Information | |||||||||
| NPI: | 1184132961 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PAVLICEK | ||||||||
| FirstName: | ELEKTRA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1560 E MAPLE RD | ||||||||
| Address2: | WSUPG PSYCHIATRY CREDENTIALING - SUITE 400 | ||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480831135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485815973 | ||||||||
| FaxNumber: | 2485815640 | ||||||||
| Practice Location | |||||||||
| Address1: | 3901 CHRYSLER DRIVE | ||||||||
| Address2: | TOLAN PARK | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139933964 | ||||||||
| FaxNumber: | 3139931372 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2018 | ||||||||
| LastUpdateDate: | 01/16/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6401014720 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.