Provider Demographics
NPI:1447701255
Name:MICHIGAN MODERN PSYCHOLOGY GROUP,PLLC
Entity type:Organization
Organization Name:MICHIGAN MODERN PSYCHOLOGY GROUP,PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:MANRIQUE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:313-561-9064
Mailing Address - Street 1:835 MASON ST
Mailing Address - Street 2:SUITE B 220
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2231
Mailing Address - Country:US
Mailing Address - Phone:313-561-9064
Mailing Address - Fax:313-563-4480
Practice Address - Street 1:835 MASON ST
Practice Address - Street 2:SUITE B 220
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2231
Practice Address - Country:US
Practice Address - Phone:313-561-9064
Practice Address - Fax:313-563-4480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-17
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P28860Medicare PIN