Provider Demographics
NPI:1528116142
Name:MILFORD PSYCHOLOGICAL SERVICES, PC
Entity type:Organization
Organization Name:MILFORD PSYCHOLOGICAL SERVICES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:248-684-6003
Mailing Address - Street 1:1042 N MILFORD RD STE 203
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48381-5109
Mailing Address - Country:US
Mailing Address - Phone:248-684-6003
Mailing Address - Fax:248-684-6007
Practice Address - Street 1:1042 N MILFORD RD STE 203
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MI
Practice Address - Zip Code:48381-5109
Practice Address - Country:US
Practice Address - Phone:248-684-6003
Practice Address - Fax:248-684-6007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012090103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOP22560Medicare ID - Type Unspecified