Basic Information
| Provider Information | |||||||||
| NPI: | 1831666288 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PETOSKEY PSYCHOLOGICAL HEALTH AND WELLNESS, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 133 | ||||||||
| Address2: | |||||||||
| City: | PETOSKEY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497700133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2313409113 | ||||||||
| FaxNumber: | 2313475194 | ||||||||
| Practice Location | |||||||||
| Address1: | 560 W MITCHELL ST STE 208 | ||||||||
| Address2: | |||||||||
| City: | PETOSKEY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497702278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2313409113 | ||||||||
| FaxNumber: | 2313475194 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2018 | ||||||||
| LastUpdateDate: | 11/09/2018 | ||||||||
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| AuthorizedOfficialLastName: | ROTH | ||||||||
| AuthorizedOfficialFirstName: | REBECCA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2313409113 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
No ID Information.