Provider Demographics
NPI:1669564837
Name:GARY J. FUSCIARDI, PHD PC
Entity type:Organization
Organization Name:GARY J. FUSCIARDI, PHD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST/ PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:FUSCIARDI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:586-323-0696
Mailing Address - Street 1:52480 SHELBY RD
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48316-3163
Mailing Address - Country:US
Mailing Address - Phone:586-323-0696
Mailing Address - Fax:586-731-8393
Practice Address - Street 1:8061 21 MILE RD
Practice Address - Street 2:SUITE #4
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48317-4311
Practice Address - Country:US
Practice Address - Phone:586-323-0696
Practice Address - Fax:586-731-8393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301005314103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5088220OtherAETNA PIN
MI9496605OtherCIGNA PIN
MI68-0E02859-0OtherBLUE CROSS AND BLUE SHIELD OF MICHIGAN
MI042893OtherVALUE OPTIONS PIN