Provider Demographics
NPI:1275571309
Name:MIKE, EDWARD JOSEPH (PHD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:JOSEPH
Last Name:MIKE
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 1:17711 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:MI
Mailing Address - Zip Code:49665-7930
Mailing Address - Country:US
Mailing Address - Phone:231-743-2141
Mailing Address - Fax:231-743-2106
Practice Address - Street 1:516 EATON ST
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:MI
Practice Address - Zip Code:48625-2508
Practice Address - Country:US
Practice Address - Phone:989-539-2553
Practice Address - Fax:989-539-2553
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2007-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301001900103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1922042555OtherMEDICARE NPI PROFESSIONAL
MI1922042555OtherMEDICARE NPI PROFESSIONAL
MI0D 74506Medicare ID - Type UnspecifiedP.C. BILLING NUMBER