Provider Demographics
NPI:1144714890
Name:PANGBORN-HARLEY, JULIA (MA)
Entity type:Individual
Prefix:
First Name:JULIA
Middle Name:
Last Name:PANGBORN-HARLEY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1129 BEACONSFIELD AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48230-2018
Mailing Address - Country:US
Mailing Address - Phone:313-405-0010
Mailing Address - Fax:
Practice Address - Street 1:5716 MICHIGAN AVE # 3000
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48210-3039
Practice Address - Country:US
Practice Address - Phone:313-963-2266
Practice Address - Fax:313-963-2471
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-17
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401016692101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional