Provider Demographics
NPI:1427229095
Name:REGENTS OF THE UNIVERSITY OF MICHIGAN PSYCHOLOGICAL CLINIC
Entity Type:Organization
Organization Name:REGENTS OF THE UNIVERSITY OF MICHIGAN PSYCHOLOGICAL CLINIC
Other - Org Name:THE PSYCHOLOGICAL CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:ASSISTANT DIRECTOR MARY A. RACKHAM
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-764-8128
Mailing Address - Street 1:500 E WASHINGTON ST STE 100
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-2057
Mailing Address - Country:US
Mailing Address - Phone:734-764-3471
Mailing Address - Fax:734-764-8128
Practice Address - Street 1:500 E WASHINGTON ST STE 100
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-2057
Practice Address - Country:US
Practice Address - Phone:734-764-3471
Practice Address - Fax:734-764-8128
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REGENTS OF THE UNIVERSITY OF MICHIGAN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-21
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1518065986OtherNPPES