Basic Information
Provider Information | |||||||||
NPI: | 1801102744 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MICHIGAN PSYCHOLOGICAL, P.C. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 29750 HARPER AVE | ||||||||
Address2: |   | ||||||||
City: | SAINT CLAIR SHORES | ||||||||
State: | MI | ||||||||
PostalCode: | 480822607 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5867773200 | ||||||||
FaxNumber: | 5867777855 | ||||||||
Practice Location | |||||||||
Address1: | 29750 HARPER AVE | ||||||||
Address2: |   | ||||||||
City: | SAINT CLAIR SHORES | ||||||||
State: | MI | ||||||||
PostalCode: | 480822607 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5867773200 | ||||||||
FaxNumber: | 5867777855 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/30/2010 | ||||||||
LastUpdateDate: | 02/23/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WARD | ||||||||
AuthorizedOfficialFirstName: | PAUL | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | CLINICAL PSYCHOLOGIST/PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 5867772300 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PH.D. | ||||||||
NPICertificationDate: | 02/23/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 6301014162 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.