Provider Demographics
NPI:1104346402
Name:ANTON, MICHAEL CHARLES (PSYD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:CHARLES
Last Name:ANTON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9919 SHADYSIDE ST
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-2715
Mailing Address - Country:US
Mailing Address - Phone:734-837-8374
Mailing Address - Fax:
Practice Address - Street 1:7800 W OUTER DR STE 300
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-3458
Practice Address - Country:US
Practice Address - Phone:313-340-4442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-27
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.008499101YP2500X
MI6301017108103T00000X, 103TC0700X
MI6301019304103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical