Provider Demographics
NPI:1952424715
Name:BELANGER, MARY COLETTE (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:COLETTE
Last Name:BELANGER
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18011 HAMILTON RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48203-4013
Mailing Address - Country:US
Mailing Address - Phone:313-278-6100
Mailing Address - Fax:313-438-0214
Practice Address - Street 1:18011 HAMILTON RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48203-4013
Practice Address - Country:US
Practice Address - Phone:313-278-6100
Practice Address - Fax:313-438-0214
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMI6301003716103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI 2758Medicare PIN