Provider Demographics
NPI:1043244585
Name:BARTLETT, PHAEDRA NOELLE
Entity Type:Individual
Prefix:
First Name:PHAEDRA
Middle Name:NOELLE
Last Name:BARTLETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9427 NASHUA TRL
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:MI
Mailing Address - Zip Code:48433-8837
Mailing Address - Country:US
Mailing Address - Phone:810-287-1425
Mailing Address - Fax:
Practice Address - Street 1:1063 S STATE RD STE 6
Practice Address - Street 2:
Practice Address - City:DAVISON
Practice Address - State:MI
Practice Address - Zip Code:48423-1900
Practice Address - Country:US
Practice Address - Phone:810-673-7211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401008276101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health