Provider Demographics
NPI:1669577201
Name:MEDICK, WILLIAM J (PHD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:J
Last Name:MEDICK
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 1:228 W WASHINGTON ST STE 7
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-4330
Mailing Address - Country:US
Mailing Address - Phone:734-241-3891
Mailing Address - Fax:734-241-0014
Practice Address - Street 1:228 W WASHINGTON ST STE 7
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-4330
Practice Address - Country:US
Practice Address - Phone:734-692-5855
Practice Address - Fax:906-273-1084
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006254103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI2879Medicare PIN