Provider Demographics
NPI:1760514681
Name:PAMELA CZUJ DBA PERSONAL DYNAMICS CENTER
Entity Type:Organization
Organization Name:PAMELA CZUJ DBA PERSONAL DYNAMICS CENTER
Other - Org Name:PERSONAL DYNAMICS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:CZUJ
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:313-563-4142
Mailing Address - Street 1:23810 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1830
Mailing Address - Country:US
Mailing Address - Phone:734-878-4965
Mailing Address - Fax:313-563-2615
Practice Address - Street 1:23810 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-1830
Practice Address - Country:US
Practice Address - Phone:734-878-4965
Practice Address - Fax:313-563-2615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1-00442101YA0400X
MI6801013746104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI054991OtherVALUE OPTIONS
MI8008919700OtherBLUE CROSS &BLUE SHIELD
MI11585836OtherCIGNA
MI0Q26323011Medicare ID - Type Unspecified
MI0Q26323Medicare PIN