Provider Demographics
NPI:1629379094
Name:MICHAEL CZARNOTA, PH.D., P.L.L.C.
Entity Type:Organization
Organization Name:MICHAEL CZARNOTA, PH.D., P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONSULTING NEUROPSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CZARNOTA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:248-253-8208
Mailing Address - Street 1:PO BOX 156
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-0156
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30055 NORTHWESTERN HWY STE 30
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-3230
Practice Address - Country:US
Practice Address - Phone:248-253-8208
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-16
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009072103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOM57900Medicare PIN