Provider Demographics
NPI:1700255585
Name:CHANG, FELICIA MICHIKO (TLLP)
Entity Type:Individual
Prefix:MS
First Name:FELICIA
Middle Name:MICHIKO
Last Name:CHANG
Suffix:
Gender:F
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:739 BRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:N9B2M5
Mailing Address - Country:CA
Mailing Address - Phone:226-345-7597
Mailing Address - Fax:
Practice Address - Street 1:79 W ALEXANDRINE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201
Practice Address - Country:US
Practice Address - Phone:313-831-5535
Practice Address - Fax:313-831-2608
Is Sole Proprietor?:No
Enumeration Date:2015-09-22
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016392103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist