1477450328 NPI number — LAKE MICHIGAN PSYCHOLOGY AND WELLNESS

Table of content: (NPI 1477450328)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477450328 NPI number — LAKE MICHIGAN PSYCHOLOGY AND WELLNESS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE MICHIGAN PSYCHOLOGY AND WELLNESS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477450328
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/26/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4066 RED ARROW HWY # 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT JOSEPH
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49085-9209
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-449-1348
Provider Business Mailing Address Fax Number:
269-999-1442

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4066 RED ARROW HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT JOSEPH
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49085-9209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-449-1348
Provider Business Practice Location Address Fax Number:
269-999-1442
Provider Enumeration Date:
10/23/2026

Additional Information

Authorized Official

Authorized Official Last Name:
OLIVEIRA
Authorized Official First Name:
CHRISTIANA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
269-449-1348

Provider Taxonomy Codes

  • Taxonomy code: 103TC1900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2026 www.npivalidator.com