Basic Information
| Provider Information | |||||||||
| NPI: | 1871931055 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLINTON COUNTY MEDICAL CENTER PSYCHOLOGICAL SERVICES PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1505 WATERFORD PKWY | ||||||||
| Address2: | |||||||||
| City: | SAINT JOHNS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488799630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9892243000 | ||||||||
| FaxNumber: | 9892240951 | ||||||||
| Practice Location | |||||||||
| Address1: | 1505 WATERFORD PKWY | ||||||||
| Address2: | |||||||||
| City: | SAINT JOHNS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488799630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9892243000 | ||||||||
| FaxNumber: | 9892240951 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2013 | ||||||||
| LastUpdateDate: | 07/31/2014 | ||||||||
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| AuthorizedOfficialLastName: | MESSENGER | ||||||||
| AuthorizedOfficialFirstName: | BRAD | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9892243000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | LLMSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 237700000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist | 101YM0800X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.