Unknown Individual – Psychiatric/Mental Health Nurse Practitioner, NPI 1508112491

Excluded from federal healthcare programs (Medicare/Medicaid)

This provider is listed on the OIG List of Excluded Individuals/Entities (LEIE). Exclusion effective: 2026-01-20. Reason: Conviction of program-related crimes (mandatory; min. 5 years).

Psychiatric/Mental Health Nurse Practitioner

Unknown Individual is a healthcare provider. based in Saint clair shores, Michigan. specializing in Psychiatric/Mental Health Nurse Practitioner. They hold a License No. 4704199416 (MI). The NPI Number for Unknown Individual is 1508112491

Main info

Organization

Inactive

16 Years Of Experience

Accepts Medicare Assignment

Name

Unknown Individual

NPI

1508112491

Phone

(586) 663-8906

Address

21031 SUNNYDALE ST

Deactivation Date

29 January 2026

Doctor Profile

Medical School Name

OTHER

Secondary Phone

5862671002

Graduation Year

2010 (16 years ago)

PAC ID

9830344258

Group Practice PAC ID

2567788813

Professional Enrollment ID

I20130308000294

Data current as of

20 May 2026

Profile Insights

NPPES metrics only — not quality of care.

Methodology

Experience14

Completeness75

Years active:0State licenses:1Digital endpointsOther names

Provider Addresses for Unknown Individual

21031 SUNNYDALE ST
SAINT CLAIR SHORES, MI 480813143
Phone: (586) 663-8906
Mailing address matches the actual address.

NPPES updates history

No NPPES updates recorded for this provider.

Prescription Activity

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Open Payments (CMS)

No Open Payments data available for this provider.

This can happen when there are no reportable CMS Open Payments records.

Medicare Enrollment & Revalidation

Source: CMS public data · Not endorsed by CMS ·

Educational use only—not medical, billing, or legal advice.

No Medicare enrollment or revalidation data available for this provider in our database.

Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS

Medicare Utilization (FFS)

Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·

Educational use only—not medical, billing, or legal advice.

No Medicare fee-for-service utilization data available for this provider in our database.

Insurance plans in this area (ZIP 48081)

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Group practice members

Group practice members are other physicians who share the same Group Practice PAC ID with this doctor. When doctors form a group practice and register in PECOS as a single entity, they receive a shared identification number. This table lists all providers in the same group practice.

PAC ID: 2567788813View full group profile