Basic Information
| Provider Information | |||||||||
| NPI: | 1467915496 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTEGRATIVE PSYCHOTHERAPY SERVICES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 44444 MOUND RD STE 650 | ||||||||
| Address2: | |||||||||
| City: | STERLING HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483141355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5866235095 | ||||||||
| FaxNumber: | 7342075326 | ||||||||
| Practice Location | |||||||||
| Address1: | 44444 MOUND RD STE 650 | ||||||||
| Address2: | |||||||||
| City: | STERLING HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483141355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5866235095 | ||||||||
| FaxNumber: | 7342075326 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2019 | ||||||||
| LastUpdateDate: | 04/08/2019 | ||||||||
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| AuthorizedOfficialLastName: | LESNIAK | ||||||||
| AuthorizedOfficialFirstName: | TAMMY | ||||||||
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| AuthorizedOfficialTitleorPosition: | LMSW/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5866235095 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LMSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1487026902 | 05 | MI | MEDICAID |