Provider Demographics
NPI:1619015872
Name:SOUTHFIELD MENTAL HEALTH ASSOCIATES PC
Entity Type:Organization
Organization Name:SOUTHFIELD MENTAL HEALTH ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:J
Authorized Official - Last Name:GUSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:248-557-3606
Mailing Address - Street 1:17320 W 12 MILE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2102
Mailing Address - Country:US
Mailing Address - Phone:248-557-3606
Mailing Address - Fax:248-557-4697
Practice Address - Street 1:17320 W 12 MILE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-2102
Practice Address - Country:US
Practice Address - Phone:248-557-3606
Practice Address - Fax:248-557-4697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI302643OtherVALUE OPTIONS
MI7509106210OtherBLUE CROSS MICHIGAN