Provider Demographics
NPI:1861031056
Name:ROSENBERG, CANDI LYN (MA, JD)
Entity Type:Individual
Prefix:
First Name:CANDI
Middle Name:LYN
Last Name:ROSENBERG
Suffix:
Gender:F
Credentials:MA, JD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1237 PILGRIM AVE
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-4804
Mailing Address - Country:US
Mailing Address - Phone:248-506-6001
Mailing Address - Fax:
Practice Address - Street 1:595 FOREST AVE STE 7AND11A
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-1775
Practice Address - Country:US
Practice Address - Phone:734-446-5466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-05
Last Update Date:2020-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301018078103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist