Basic Information
| Provider Information | |||||||||
| NPI: | 1528208873 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GERIATRIC PSYCHIATRIC SERVICES PLLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | GPS INDIANA LMSW GROUP | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 28800 RYAN RD | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480924272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5686208100 | ||||||||
| FaxNumber: | 8662277418 | ||||||||
| Practice Location | |||||||||
| Address1: | 1721 MOON LAKE BLVD | ||||||||
| Address2: | |||||||||
| City: | HOFFMAN ESTATES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601691069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475193650 | ||||||||
| FaxNumber: | 8475193642 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2009 | ||||||||
| LastUpdateDate: | 10/14/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CLEMENTE | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5866208100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GERIATRIC PSYCHIATRIC SERVICES PLLC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.