Provider Demographics
NPI:1598356537
Name:MICHAEL, MARILYN S (MA, LLP)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:S
Last Name:MICHAEL
Suffix:
Gender:F
Credentials:MA, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 FRANK RD
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48362-1718
Mailing Address - Country:US
Mailing Address - Phone:248-977-2964
Mailing Address - Fax:
Practice Address - Street 1:27172 WOODWARD AVE
Practice Address - Street 2:STE 200
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-0965
Practice Address - Country:US
Practice Address - Phone:248-546-0407
Practice Address - Fax:866-422-3133
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361001241103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty