Provider Demographics
NPI:1760752976
Name:MITCHELL S. WEISBROD, PSY.D., PLLC
Entity Type:Organization
Organization Name:MITCHELL S. WEISBROD, PSY.D., PLLC
Other - Org Name:MITCHELL S. WEISBROD, PSY.D.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:WEISBROD
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:517-544-7700
Mailing Address - Street 1:115 S WEST AVE STE 1
Mailing Address - Street 2:
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 1:115 S WEST AVE STE 1
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-2085
Practice Address - Country:US
Practice Address - Phone:517-544-7700
Practice Address - Fax:517-612-8817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-04
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008984103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty