Provider Demographics
NPI:1043249469
Name:PERADOTTO, DAVID (PHD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:PERADOTTO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43450 W 10 MILE RD
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-3172
Mailing Address - Country:US
Mailing Address - Phone:248-344-7420
Mailing Address - Fax:248-344-7423
Practice Address - Street 1:43450 W 10 MILE RD
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-3172
Practice Address - Country:US
Practice Address - Phone:248-344-7420
Practice Address - Fax:248-344-7423
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008098103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI680F333060OtherBC PIN
MI300040030OtherNPC TAX ID
MI273178OtherVO
MI680F321030OtherBC PIN
MI273178OtherBCN PIN