Provider Demographics
NPI:1053486142
Name:FRIEDBERG, LARRY MARK (PHD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:MARK
Last Name:FRIEDBERG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31600 TELEGRAPH ROAD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:BINGHAM FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-4372
Mailing Address - Country:US
Mailing Address - Phone:248-965-9532
Mailing Address - Fax:248-671-3203
Practice Address - Street 1:31600 TELEGRAPH ROAD
Practice Address - Street 2:SUITE 250
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-4372
Practice Address - Country:US
Practice Address - Phone:248-965-9532
Practice Address - Fax:248-671-3203
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301005034103TC2200X, 103TA0700X, 103TF0000X, 103TF0200X, 103TC0700X, 103T00000X
103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI38-1864342Medicare UPIN