Basic Information
| Provider Information | |||||||||
| NPI: | 1619315538 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | APEX BEHAVIORAL HEALTH WESTERN-WAYNE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1547 S WAYNE RD | ||||||||
| Address2: | |||||||||
| City: | WESTLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481865436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347293133 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1547 S WAYNE RD | ||||||||
| Address2: | |||||||||
| City: | WESTLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481865436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347293133 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2013 | ||||||||
| LastUpdateDate: | 10/22/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PARK | ||||||||
| AuthorizedOfficialFirstName: | TAE | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | PSYCHIATRIST | ||||||||
| AuthorizedOfficialTelephone: | 7347293133 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.