Basic Information
| Provider Information | |||||||||
| NPI: | 1780956995 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIMON | ||||||||
| FirstName: | CAROLYN | ||||||||
| MiddleName: | JEAN | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 27009 FARMBROOK VILLA DR | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480341041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484709959 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 26522 VAN DYKE AVE | ||||||||
| Address2: | |||||||||
| City: | CENTER LINE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480151221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867594400 | ||||||||
| FaxNumber: | 5867594401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2012 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 6401012669 | MI | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP1600X | 6401012669 | MI | N | Behavioral Health & Social Service Providers | Counselor | Pastoral | 101YP2500X | 64011012669 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.