Provider Demographics
NPI:1629141007
Name:WEISBROD, MITCHELL SCOTT (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:SCOTT
Last Name:WEISBROD
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 S WEST AVE
Mailing Address - Street 2:STE 1
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-2085
Mailing Address - Country:US
Mailing Address - Phone:517-544-7700
Mailing Address - Fax:517-612-8817
Practice Address - Street 1:202 N WEST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1903
Practice Address - Country:US
Practice Address - Phone:517-544-7700
Practice Address - Fax:517-780-9239
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008984103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI15370001Medicare PIN