Provider Demographics
NPI:1588755672
Name:JARUZEL, MARK ELLIS II (PSYD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ELLIS
Last Name:JARUZEL
Suffix:II
Gender:M
Credentials:PSYD
Other - Prefix:DR
Other - First Name:M.
Other - Middle Name:ELLIS
Other - Last Name:JARUZEL
Other - Suffix:II
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:947-522-1865
Mailing Address - Fax:
Practice Address - Street 1:2001 S MERRIMAN RD STE 100
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48186-5540
Practice Address - Country:US
Practice Address - Phone:734-727-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301017838103TC0700X, 103TC0700X
MI6301016608103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6301016608OtherBOARD OF PSYCHOLOGY STATE OF MICHIGAN