Provider Demographics
NPI:1295875789
Name:WEISS, RICHARD LOUIS (PH D)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:LOUIS
Last Name:WEISS
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37899 WEST TWELVE MILE ROAD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331
Mailing Address - Country:US
Mailing Address - Phone:248-489-3030
Mailing Address - Fax:248-489-3131
Practice Address - Street 1:37899 WEST TWELVE MILE ROAD
Practice Address - Street 2:SUITE 310
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48331
Practice Address - Country:US
Practice Address - Phone:248-489-3030
Practice Address - Fax:248-489-3131
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401002173101YP2500X
MI6301001687103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
R67190Medicare UPIN
MI0F34815Medicare ID - Type Unspecified