NPIMap

Organization Active NPI

Michigan Modern Psychology Group,PLLC

  • Clinical Psychologist
  • Dearborn, MI
National Provider Identifier
1447701255
Registry record updated May 29, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical PsychologistTaxonomy code 103TC0700X
Legal business name
MICHIGAN MODERN PSYCHOLOGY GROUP,PLLC
Practice address
835 Mason St
Suite B 220
Dearborn, MI 48124-2231
Phone
(313) 561-9064
Fax
(313) 563-4480
NPI assigned
Oct 17, 2016
Last updated
May 29, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 29, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Manuel A Manrique, PHDNPI 1588710222
Title
Director
Phone
(313) 561-9064

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical PsychologistGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 103TC0700X Primary

Addresses

Primary practice location

835 Mason St
Suite B 220
Dearborn, MI 48124-2231

Mailing address

835 Mason St
Suite B 220
Dearborn, MI 48124-2231
Phone (313) 561-9064

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20190117001322 MI Part B Supplier - Clinic/Group Practice 6103162896 Receives reassigned benefits from 15 practitioners
Practice locations: Dearborn, MI

National Provider Directory

National Provider Directory

Locations

835 Mason St
Ste B220
Dearborn, MI 48124
Phone 3135619064 ext. 102

Practitioners & affiliated clinicians

Practitioners 51

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 51

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1476662400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1716940800000",
    "number": "1447701255",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "835 MASON ST",
            "address_2": "SUITE B 220",
            "city": "DEARBORN",
            "state": "MI",
            "postal_code": "481242231",
            "telephone_number": "313-561-9064",
            "fax_number": "313-563-4480"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "835 MASON ST",
            "address_2": "SUITE B 220",
            "city": "DEARBORN",
            "state": "MI",
            "postal_code": "481242231",
            "telephone_number": "313-561-9064",
            "fax_number": "313-563-4480"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MICHIGAN MODERN PSYCHOLOGY GROUP,PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-10-17",
        "last_updated": "2024-05-29",
        "certification_date": "2024-05-29",
        "status": "A",
        "authorized_official_last_name": "MANRIQUE",
        "authorized_official_first_name": "MANUEL",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "DIRECTOR",
        "authorized_official_telephone_number": "313-561-9064",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "PHD"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Psychologist, Clinical",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Dearborn, MI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 29, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.