Provider Demographics
NPI:1225703069
Name:STASZKOW, RICHARD (PHD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:STASZKOW
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 1:26555 EVERGREEN RD STE 830
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-4239
Mailing Address - Country:US
Mailing Address - Phone:248-350-3650
Mailing Address - Fax:248-350-1216
Practice Address - Street 1:26555 EVERGREEN RD STE 830
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-4239
Practice Address - Country:US
Practice Address - Phone:248-350-3650
Practice Address - Fax:248-350-1216
Is Sole Proprietor?:No
Enumeration Date:2021-08-13
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015513103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist