Basic Information
| Provider Information | |||||||||
| NPI: | 1205965225 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FELDMAN | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | CHARLES | ||||||||
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| Credential: | MA, LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 461 W HURON ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484561991 | ||||||||
| FaxNumber: | 2484568151 | ||||||||
| Practice Location | |||||||||
| Address1: | 461 W HURON ST | ||||||||
| Address2: | STE 100 | ||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483411601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484561991 | ||||||||
| FaxNumber: | 2484568151 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 06/20/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 6401006740 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1883825 | 05 | MI | MEDICAID |