Provider Demographics
NPI:1679641583
Name:LONGAN, PATRICIA RESEK (PH D)
Entity type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:RESEK
Last Name:LONGAN
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:
Other - Last Name:RESEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6500 CENTURION DRIVE
Mailing Address - Street 2:SUITE 260
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-8240
Mailing Address - Country:US
Mailing Address - Phone:517-886-0445
Mailing Address - Fax:517-886-0445
Practice Address - Street 1:6500 CENTURION DRIVE
Practice Address - Street 2:SUITE 260
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-8240
Practice Address - Country:US
Practice Address - Phone:517-886-0445
Practice Address - Fax:517-886-0445
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301000963103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P17510Medicare ID - Type Unspecified