Provider Demographics
NPI:1033924071
Name:DOUGLAS, BYRON C (PHD)
Entity type:Individual
Prefix:
First Name:BYRON
Middle Name:C
Last Name:DOUGLAS
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 1:8553 WINDSOR CT
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198-3613
Mailing Address - Country:US
Mailing Address - Phone:313-910-8473
Mailing Address - Fax:
Practice Address - Street 1:2512 HARTE DR
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48114-7002
Practice Address - Country:US
Practice Address - Phone:248-761-0998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-07
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006483103T00000X, 103TC0700X
103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist