Provider Demographics
NPI:1346738770
Name:IDENTITY COUNSELING PSYCHOLOGY PLLC
Entity Type:Organization
Organization Name:IDENTITY COUNSELING PSYCHOLOGY PLLC
Other - Org Name:WILKINS COUNSELING PSYCHOLOGY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:LPC
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-645-8944
Mailing Address - Street 1:2350 WASHTENAW AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-4525
Mailing Address - Country:US
Mailing Address - Phone:734-645-8944
Mailing Address - Fax:734-645-8944
Practice Address - Street 1:2350 WASHTENAW AVE STE 4
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104
Practice Address - Country:US
Practice Address - Phone:734-645-8944
Practice Address - Fax:734-645-8944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-01
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty