Basic Information
| Provider Information | |||||||||
| NPI: | 1275690760 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PIERCE | ||||||||
| FirstName: | CATHERINE | ||||||||
| MiddleName: | VITA | ||||||||
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| Credential: | PLD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2333 BIDDLE ST | ||||||||
| Address2: | |||||||||
| City: | WYANDOTTE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481924668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342466000 | ||||||||
| FaxNumber: | 7342466990 | ||||||||
| Practice Location | |||||||||
| Address1: | 2333 BIDDLE ST | ||||||||
| Address2: | |||||||||
| City: | WYANDOTTE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481924668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342466000 | ||||||||
| FaxNumber: | 7342466990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2007 | ||||||||
| LastUpdateDate: | 05/21/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 6301002565 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | $$$$$$$$$ | 01 | MI | SOCIAL SECURITY | OTHER | 6301002565 | 01 | MI | LICENSE | OTHER |