Provider Demographics
NPI:1821327222
Name:AMY J. TRABITZ, PH.D., P.C.
Entity Type:Organization
Organization Name:AMY J. TRABITZ, PH.D., P.C.
Other - Org Name:AMY J. CHARNESS
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:J
Authorized Official - Last Name:TRABITZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:313-359-3161
Mailing Address - Street 1:23810 MICHIGAN AVE
Mailing Address - Street 2:SUITE 202B
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1830
Mailing Address - Country:US
Mailing Address - Phone:313-359-3161
Mailing Address - Fax:313-359-4811
Practice Address - Street 1:23810 MICHIGAN AVE
Practice Address - Street 2:SUITE 202B
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-1830
Practice Address - Country:US
Practice Address - Phone:313-359-3161
Practice Address - Fax:313-359-4811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-14
Last Update Date:2013-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006103261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health