Provider Demographics
NPI:1871560326
Name:WUNSCH, MARTIN GERARD (PHD)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:GERARD
Last Name:WUNSCH
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 1:1728 BRENTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-2630
Mailing Address - Country:US
Mailing Address - Phone:586-263-0947
Mailing Address - Fax:248-267-5899
Practice Address - Street 1:43211 DALCOMA DR
Practice Address - Street 2:SUITE 11
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-6309
Practice Address - Country:US
Practice Address - Phone:586-263-0947
Practice Address - Fax:248-267-5899
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-03
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301005658103G00000X, 103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI122159OtherVALUE OPTIONS
MI207862OtherMANAGED HEALTH NETWORK, I
MI5076046OtherAETNA BEHAVIORAL HEALTH
MI68OF33054OtherBLUE CROSS BLUE SHIELD
MI5842OtherHEALTH NET
MI071777000OtherMAGELLAN HEALTH SERVICES
MIIP045740OtherTRICARE