Basic Information
| Provider Information | |||||||||
| NPI: | 1417055385 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ENDRES | ||||||||
| FirstName: | DEBORAH | ||||||||
| MiddleName: | ANN-MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LLP, LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DERMIDOFF | ||||||||
| OtherFirstName: | DEBORAH | ||||||||
| OtherMiddleName: | ANN-MARIE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 28000 DEQUINDRE RD | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480922468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867530405 | ||||||||
| FaxNumber: | 5867530404 | ||||||||
| Practice Location | |||||||||
| Address1: | 35455 GARFIELD RD | ||||||||
| Address2: | |||||||||
| City: | CLINTON TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480352236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867925335 | ||||||||
| FaxNumber: | 5867923061 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 01/12/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 6401007287 | MI | Y | Behavioral Health & Social Service Providers | Counselor | 103T00000X | 6301007765 | MI | N | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.