Basic Information
| Provider Information | |||||||||
| NPI: | 1437547460 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PREMIER PROFESSIONAL GROUP LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 42450 W 12 MILE RD | ||||||||
| Address2: | STE 315 | ||||||||
| City: | NOVI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483773013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485134100 | ||||||||
| FaxNumber: | 2485134105 | ||||||||
| Practice Location | |||||||||
| Address1: | 42450 W 12 MILE RD | ||||||||
| Address2: | STE 315 | ||||||||
| City: | NOVI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483773013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485134100 | ||||||||
| FaxNumber: | 2485134105 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2014 | ||||||||
| LastUpdateDate: | 10/20/2015 | ||||||||
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| AuthorizedOfficialLastName: | BERKOVITZ | ||||||||
| AuthorizedOfficialFirstName: | DAHLIA | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 2485134100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 104100000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 2084P0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.