Provider Demographics
NPI:1205134525
Name:MICHIGAN BEHAVIORAL MEDICINE
Entity type:Organization
Organization Name:MICHIGAN BEHAVIORAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:RENE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOSEPH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-703-1897
Mailing Address - Street 1:2525 CROOKS RD STE 100
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-4733
Mailing Address - Country:US
Mailing Address - Phone:248-731-7305
Mailing Address - Fax:248-731-7288
Practice Address - Street 1:2525 CROOKS RD STE 100
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4733
Practice Address - Country:US
Practice Address - Phone:248-731-7305
Practice Address - Fax:248-731-7288
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MICHIGAN BEHAVIORAL MEDICINE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-03-10
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI103G00000X, 103T00000X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1922195999OtherTYPE 2 NPI