Provider Demographics
NPI:1649210931
Name:CONNELL, DAVID MICHAEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MICHAEL
Last Name:CONNELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27787 MARTINDALE RD
Mailing Address - Street 2:
Mailing Address - City:NEW HUDSON
Mailing Address - State:MI
Mailing Address - Zip Code:48165-9601
Mailing Address - Country:US
Mailing Address - Phone:248-264-6400
Mailing Address - Fax:248-347-3393
Practice Address - Street 1:INNER WISDOM COUNSELING
Practice Address - Street 2:224 S. MAIN
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167
Practice Address - Country:US
Practice Address - Phone:248-348-1270
Practice Address - Fax:248-347-3393
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301005242103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI578408Medicare UPIN