Provider Demographics
NPI:1669427639
Name:MITTELMAN, DAVID (PHD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:MITTELMAN
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 1:29551 GREENFIELD RD STE 204
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-5872
Mailing Address - Country:US
Mailing Address - Phone:248-980-8349
Mailing Address - Fax:248-848-3592
Practice Address - Street 1:29551 GREENFIELD RD STE 204
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-5872
Practice Address - Country:US
Practice Address - Phone:248-980-8349
Practice Address - Fax:248-848-3592
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI007389103T00000X, 103TC0700X
103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP12130006Medicare ID - Type UnspecifiedINDIVIDUAL ID NUMBER