Provider Demographics
| NPI: | 1073647731 |
|---|---|
| Name: | BURDETTE AND DOSS PSYCHOLOGICAL SERVICES LC |
| Entity Type: | Organization |
| Organization Name: | BURDETTE AND DOSS PSYCHOLOGICAL SERVICES LC |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | ADMINISTRATIVE DIRECTOR |
| Authorized Official - Prefix: | MS |
| Authorized Official - First Name: | BARBARA ANN |
| Authorized Official - Middle Name: | ELISABETH |
| Authorized Official - Last Name: | TYSELL |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 248-559-0730 |
| Mailing Address - Street 1: | 17352 W 12 MILE RD |
| Mailing Address - Street 2: | SUITE 100 |
| Mailing Address - City: | SOUTHFIELD |
| Mailing Address - State: | MI |
| Mailing Address - Zip Code: | 48076-2119 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 248-559-0730 |
| Mailing Address - Fax: | 248-569-7626 |
| Practice Address - Street 1: | 17352 W 12 MILE RD |
| Practice Address - Street 2: | SUITE 100 |
| Practice Address - City: | SOUTHFIELD |
| Practice Address - State: | MI |
| Practice Address - Zip Code: | 48076-2119 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 248-559-0730 |
| Practice Address - Fax: | 248-569-7626 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2007-03-15 |
| Last Update Date: | 2008-10-28 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| 101Y00000X, 101YA0400X, 101YM0800X, 101YP2500X, 103T00000X, 103TC0700X, 103TC2200X, 103TP0814X, 1041C0700X, 106H00000X, 2084P0800X | ||
| MI | 630534 | 261QM0801X, 261QR0405X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 261QM0801X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | Group - Multi-Specialty |
| No | 101Y00000X | Behavioral Health & Social Service Providers | Counselor | Group - Multi-Specialty | |
| No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
| No | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health | Group - Multi-Specialty |
| No | 101YP2500X | Behavioral Health & Social Service Providers | Counselor | Professional | Group - Multi-Specialty |
| No | 103T00000X | Behavioral Health & Social Service Providers | Psychologist | Group - Multi-Specialty | |
| No | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical | Group - Multi-Specialty |
| No | 103TC2200X | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | Group - Multi-Specialty |
| No | 103TP0814X | Behavioral Health & Social Service Providers | Psychologist | Psychoanalysis | Group - Multi-Specialty |
| No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
| No | 106H00000X | Behavioral Health & Social Service Providers | Marriage & Family Therapist | Group - Multi-Specialty | |
| No | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Multi-Specialty |
| No | 261QR0405X | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| MI | 750910921 | Other | BCBS TRADITIONAL CODE |
| MI | 20700 | Other | BCBS SUB AB AND MGD CARE |
| MI | 7509109210 | Other | BCBS NASCO IDENTIFIER |
| MI | 1316097488 | Other | NPPESJAMES A. COWLEY NPI |
| MI | 26 0 F3 2684 0 | Other | NASCO GROUP TRACKING ID |
| MI | 38314498 | Other | HAP PROVIDER ID |
| MI | 7509109210 | Other | VALUEOPTIONS |
| MI | 0911921 | Other | BCBS PROVIDER ID MDS |
| MI | 0913921 | Other | BCBS PROVIDER ID MASTERS |
| MI | 630534 | Other | STATE SUBSTANCE ABUSE LIC |
| MI | 0912921 | Other | BCBS PROVIDER ID PHDS |
| MI | 10921 | Other | BCBS MANAGED CARE CODE |
| MI | F037350 | Other | WEB DENIS IDENTIFIER |
| MI | 187925000 | Other | MAGELLAN IDENTIFIER |
| MI | 0910921 | Other | BCBS OF MICHIGAN |
| MI | 125750 | Other | VALUE OPTIONS PROVIDER ID |
| MI | P69427 | Other | BLUE CARE NETWORK PIN |
| MI | 0M67590 | Medicare ID - Type Unspecified | JAMES COWLEY LSW MASTERS |
| MI | 0F37268001 | Medicare PIN | |
| MI | 0913921 | Other | BCBS PROVIDER ID MASTERS |
| MI | F037350 | Other | WEB DENIS IDENTIFIER |
| MI | 125750 | Other | VALUE OPTIONS PROVIDER ID |
| MI | OM30330 | Medicare ID - Type Unspecified | EDWARD ROBERTS MD AND MDS |
| MI | 0F37268011 | Medicare PIN | |
| MI | 20700 | Other | BCBS SUB AB AND MGD CARE |
| MI | 10921 | Other | BCBS MANAGED CARE CODE |
| MI | F43390 | Medicare UPIN | |
| MI | 7509109210 | Other | BCBS NASCO IDENTIFIER |
