Provider Demographics
| NPI: | 1306999628 |
|---|---|
| Name: | BEAN, JUDITH A (PHD) |
| Entity type: | Individual |
| Prefix: | DR |
| First Name: | JUDITH |
| Middle Name: | A |
| Last Name: | BEAN |
| Suffix: | |
| Gender: | F |
| Credentials: | PHD |
| Other - Prefix: | DR |
| Other - First Name: | JUDITH |
| Other - Middle Name: | ANN |
| Other - Last Name: | BEAN |
| Other - Suffix: | |
| Other - Last Name Type: | Professional Name |
| Other - Credentials: | PHD |
| Mailing Address - Street 1: | 1937 LONE PINE RD |
| Mailing Address - Street 2: | |
| Mailing Address - City: | BLOOMFIELD HILLS |
| Mailing Address - State: | MI |
| Mailing Address - Zip Code: | 48302-2522 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 248-626-9729 |
| Mailing Address - Fax: | 248-626-3299 |
| Practice Address - Street 1: | 24500 FORD RD |
| Practice Address - Street 2: | |
| Practice Address - City: | DEARBORN HEIGHTS |
| Practice Address - State: | MI |
| Practice Address - Zip Code: | 48127-3182 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 313-563-0919 |
| Practice Address - Fax: | 313-563-0826 |
| Is Sole Proprietor?: | No |
| Enumeration Date: | 2007-01-19 |
| Last Update Date: | 2008-04-25 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| MI | 6301001417 | 103G00000X, 103TA0400X, 103TA0700X, 103TB0200X, 103TC0700X, 103TC1900X, 103TC2200X, 103TF0000X, 103TF0200X, 103TM1800X, 103TP2701X, 103TS0200X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization |
|---|---|---|---|---|
| Yes | 103G00000X | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | |
| No | 103TA0400X | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) |
| No | 103TA0700X | Behavioral Health & Social Service Providers | Psychologist | Adult Development & Aging |
| No | 103TB0200X | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral |
| No | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical |
| No | 103TC1900X | Behavioral Health & Social Service Providers | Psychologist | Counseling |
| No | 103TC2200X | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
| No | 103TF0000X | Behavioral Health & Social Service Providers | Psychologist | Family |
| No | 103TF0200X | Behavioral Health & Social Service Providers | Psychologist | Forensic |
| No | 103TM1800X | Behavioral Health & Social Service Providers | Psychologist | Intellectual & Developmental Disabilities |
| No | 103TP2701X | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy |
| No | 103TS0200X | Behavioral Health & Social Service Providers | Psychologist | School |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| R81188 | Medicare UPIN | ||
| MI | OP41350 | Medicare PIN |
