Basic Information
| Provider Information | |||||||||
| NPI: | 1689015703 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EAST LANSING PSYCHOLOGICAL SERVICES PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10 | ||||||||
| Address2: | |||||||||
| City: | MASON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488540010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5176769788 | ||||||||
| FaxNumber: | 5176763438 | ||||||||
| Practice Location | |||||||||
| Address1: | 121 BURCHAM DR | ||||||||
| Address2: | |||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488232703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5174201377 | ||||||||
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| ProviderEnumerationDate: | 07/17/2013 | ||||||||
| LastUpdateDate: | 07/17/2013 | ||||||||
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| AuthorizedOfficialLastName: | HATHAWAY | ||||||||
| AuthorizedOfficialFirstName: | EILEEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5174201377 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LLP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 6301009001 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.