Basic Information
| Provider Information | |||||||||
| NPI: | 1760082762 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FRICK | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 28303 DEQUINDRE RD | ||||||||
| Address2: | |||||||||
| City: | MADISON HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480713040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486581116 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 28303 DEQUINDRE RD | ||||||||
| Address2: | |||||||||
| City: | MADISON HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480713040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486581116 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2020 | ||||||||
| LastUpdateDate: | 10/28/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 6401018458 | MI | N | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | 6401018458 | MI | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 6401018458 | MI | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YA0400X | 6401018458 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.