Basic Information
| Provider Information | |||||||||
| NPI: | 1417575762 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AUTHENTICITY PSYCHOLOGICAL SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24314 CHERRY HILL ST | ||||||||
| Address2: | |||||||||
| City: | DEARBORN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481241358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7733185567 | ||||||||
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| Practice Location | |||||||||
| Address1: | 24314 CHERRY HILL ST | ||||||||
| Address2: | |||||||||
| City: | DEARBORN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481241358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7733185567 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2020 | ||||||||
| LastUpdateDate: | 07/15/2020 | ||||||||
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| AuthorizedOfficialLastName: | FARRELL | ||||||||
| AuthorizedOfficialFirstName: | MELISSA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PSYCHOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 7733185567 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| NPICertificationDate: | 07/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.