Taxonomy Codes
The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:
| No. |
Taxonomy Code |
Taxonomy Clasification |
Taxonomy Specialization |
License Number |
License State |
Primary |
| 1 | 103TC0700X | Psychologist | Clinical | N/A | MICHIGAN | No |
| 2 | 2084P0800X | Psychiatry & Neurology | Psychiatry | N/A | MICHIGAN | No |
| 3 | 251C00000X | Day Training, Developmentally Disabled Services | | | MICHIGAN | No |
| 4 | 1041C0700X | Social Worker | Clinical | | | Yes |
Other Identifiers
The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.
| No. |
Other Provider Identifier |
Other Provider Identifier Type |
Other Provider Identifier State |
Other Provider Identifier Issuer |
| 1 | 77353 | OTHER | MICHIGAN | SHELBY CIGNA PIN # |
| 2 | 20528 | OTHER | MICHIGAN | BLUE CROSS S/A |
| 3 | M07925 | OTHER | MICHIGAN | HAP PIN #- ALL SITES |
| 4 | 750910612 | OTHER | MICHIGAN | CLINTON BLUE CROSS PIN # |
| 5 | 0M10460 | MEDICARE PIN | MICHIGAN | |
| 6 | 750910526 | OTHER | MICHIGAN | RICHMOND BLUE CROSS PIN # |
| 7 | 0M10270 | MEDICARE PIN | MICHIGAN | |
| 8 | 20389 | OTHER | MICHIGAN | BLUE CROSS S/A |
| 9 | 3396315 | MEDICAID | MICHIGAN | |
| 10 | 750910710 | OTHER | MICHIGAN | BLUE CROSS BLUE SHIELD |
| 11 | 20572 | OTHER | MICHIGAN | BLUE CROSS S/A |
| 12 | 2066282 | OTHER | MICHIGAN | ROMEO CIGNA PIN # |
| 13 | 125267 | OTHER | MICHIGAN | VALUE OPTIONS PIN # - ALL |
| 14 | 13305 | OTHER | MICHIGAN | CLINTON CIGNA PIN # |
| 15 | 2068754 | OTHER | MICHIGAN | RICHMOND CIGNA PIN # |
| 16 | 20531 | OTHER | MICHIGAN | BLUE CROSS S/A |
| 17 | 750910529 | OTHER | MICHIGAN | ROMEO BLUE CROSS PIN # |
| 18 | 750910671 | OTHER | MICHIGAN | SHELBY BLUE CROSS PIN # |
