Basic Information
| Provider Information | |||||||||
| NPI: | 1801069323 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SALLY BLOCH PHD LP PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 939 RIVENOAK ST | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480095737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483433318 | ||||||||
| FaxNumber: | 2485227365 | ||||||||
| Practice Location | |||||||||
| Address1: | 4190 TELEGRAPH RD STE 2700 | ||||||||
| Address2: | |||||||||
| City: | BLOOMFIELD HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483022042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483433318 | ||||||||
| FaxNumber: | 2485227365 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2008 | ||||||||
| LastUpdateDate: | 06/25/2020 | ||||||||
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| AuthorizedOfficialLastName: | BLOCH | ||||||||
| AuthorizedOfficialFirstName: | SALLY | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | PSYCHOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 2483433318 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
| NPICertificationDate: | 06/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 6301006311 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 0F32753 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER |