Basic Information
| Provider Information | |||||||||
| NPI: | 1255759486 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAKE ORION COUNSELING CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LAKE ORION COUNSELING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3604 CLARKSTON RD | ||||||||
| Address2: | |||||||||
| City: | CLARKSTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483485215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485959969 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3604 CLARKSTON RD | ||||||||
| Address2: | |||||||||
| City: | CLARKSTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483485215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485959969 | ||||||||
| FaxNumber: | 2488140361 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2014 | ||||||||
| LastUpdateDate: | 08/18/2021 | ||||||||
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| AuthorizedOfficialLastName: | PASCIAK | ||||||||
| AuthorizedOfficialFirstName: | ADAM | ||||||||
| AuthorizedOfficialMiddleName: | ROSS | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL PSYCHOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 2488079894 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHD, LP | ||||||||
| NPICertificationDate: | 08/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 103T00000X | 6301015095 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 6301015095 | 05 | MI | MEDICAID |