Provider Demographics
NPI:1881762250
Name:FANDRICK, RONALD DALE (PHD)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:DALE
Last Name:FANDRICK
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 1:333 STOLL RD
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-3418
Mailing Address - Country:US
Mailing Address - Phone:517-290-6228
Mailing Address - Fax:517-323-4531
Practice Address - Street 1:3815 W SAINT JOSEPH ST STE A400
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-5600
Practice Address - Country:US
Practice Address - Phone:517-323-4531
Practice Address - Fax:517-323-4531
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008822103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist