Basic Information
| Provider Information | |||||||||
| NPI: | 1780832709 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LLEWELLYN | ||||||||
| FirstName: | JEFFERY | ||||||||
| MiddleName: | FOSTER | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8463 THORNTREE DR | ||||||||
| Address2: | |||||||||
| City: | GROSSE ILE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481381587 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347857705 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 13101 ALLEN RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SOUTHGATE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481952216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347857705 | ||||||||
| FaxNumber: | 7347857731 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2008 | ||||||||
| LastUpdateDate: | 09/03/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 6301013733 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.