Provider Demographics
NPI:1598842908
Name:BLOCH, SALLY (PHD)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:BLOCH
Suffix:
Gender:F
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:PO BOX 2257
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-0357
Mailing Address - Country:US
Mailing Address - Phone:219-926-8320
Mailing Address - Fax:219-926-3524
Practice Address - Street 1:4190 TELEGRAPH RD STE 2700
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-2042
Practice Address - Country:US
Practice Address - Phone:248-343-3318
Practice Address - Fax:248-522-7365
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006311103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI680F327530OtherBLUE CROSS BLUE SHIELD