Provider Demographics
NPI:1720570369
Name:GADD, JAMES
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:GADD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50258 VAN DYKE AVE
Mailing Address - Street 2:
Mailing Address - City:SHELBY TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48317-1374
Mailing Address - Country:US
Mailing Address - Phone:586-884-4714
Mailing Address - Fax:
Practice Address - Street 1:50258 VAN DYKE AVE
Practice Address - Street 2:
Practice Address - City:SHELBY TWP
Practice Address - State:MI
Practice Address - Zip Code:48317-1374
Practice Address - Country:US
Practice Address - Phone:586-884-4714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-30
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401011692101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI813601247Medicaid