Provider Demographics
NPI:1467527127
Name:ANTHONY, BART (MALLP)
Entity Type:Individual
Prefix:
First Name:BART
Middle Name:
Last Name:ANTHONY
Suffix:
Gender:M
Credentials:MALLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29830 W 12 MILE RD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-4030
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:29830 W 12 MILE RD
Practice Address - Street 2:SUITE 303
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-4030
Practice Address - Country:US
Practice Address - Phone:810-333-2274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011486103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical