Provider Demographics
NPI:1376742056
Name:LEDGERWOOD, DAVID M (PHD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:LEDGERWOOD
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 1:1560 E MAPLE RD
Mailing Address - Street 2:SUITE 400- CREDENTIALING DEPARTMENT
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1138
Mailing Address - Country:US
Mailing Address - Phone:313-993-3964
Mailing Address - Fax:313-993-1372
Practice Address - Street 1:3901 CHRYSLER SERVICE DR
Practice Address - Street 2:TOLAN PARK
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2167
Practice Address - Country:US
Practice Address - Phone:313-993-3964
Practice Address - Fax:313-993-1372
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013525103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist