Provider Demographics
NPI:1992963607
Name:DAITCH, CAROLYN (PHD)
Entity type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:
Last Name:DAITCH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28592 ORCHARD LAKE RD
Mailing Address - Street 2:#301
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-2961
Mailing Address - Country:US
Mailing Address - Phone:248-626-8151
Mailing Address - Fax:248-626-7277
Practice Address - Street 1:28592 ORCHARD LAKE RD
Practice Address - Street 2:#301
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-2961
Practice Address - Country:US
Practice Address - Phone:248-626-8151
Practice Address - Fax:248-626-7277
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301002465103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOM53740Medicare PIN