Provider Demographics
NPI:1871822890
Name:BIENIEK, DOUGLAS SCOTT
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:SCOTT
Last Name:BIENIEK
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 1:3785 VETERANS DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-4516
Mailing Address - Country:US
Mailing Address - Phone:231-946-8975
Mailing Address - Fax:
Practice Address - Street 1:3785 VETERANS DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-4516
Practice Address - Country:US
Practice Address - Phone:231-946-8975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-22
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401012409101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional