Provider Demographics
NPI:1649664467
Name:COGNITIVE CARE CENTER PC
Entity type:Organization
Organization Name:COGNITIVE CARE CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MSLLP
Authorized Official - Prefix:
Authorized Official - First Name:JUVARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:JAVAID
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-330-7281
Mailing Address - Street 1:43155 MAIN ST
Mailing Address - Street 2:ATRIUM 2300 SUITE O
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-1777
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:43155 MAIN ST
Practice Address - Street 2:ATRIUM 2300 SUITE O
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-1777
Practice Address - Country:US
Practice Address - Phone:248-330-7281
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-19
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013794103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6301013794Medicaid