Provider Demographics
NPI:1417924200
Name:TRASK, JOHN H (PHD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:H
Last Name:TRASK
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 1:200 E BIG BEAVER RD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1208
Mailing Address - Country:US
Mailing Address - Phone:248-689-4600
Mailing Address - Fax:248-519-1201
Practice Address - Street 1:650 E BIG BEAVER RD
Practice Address - Street 2:SUITE A
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-1432
Practice Address - Country:US
Practice Address - Phone:248-689-4600
Practice Address - Fax:248-519-1201
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007751103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1164693362OtherNPPES
MI68-0-F3-2859-0OtherBLUE CROSS BLUE SHIELD MI
1164693362OtherNPPES
MIP23770001Medicare ID - Type Unspecified