1518093871 NPI number — ADULT FAMILY & GROUP COUNSELING PLLC

Table of content: (NPI 1518093871)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518093871 NPI number — ADULT FAMILY & GROUP COUNSELING PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADULT FAMILY & GROUP COUNSELING PLLC
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:
1518093871
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/14/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10426 V.05 RD
Provider Second Line Business Mailing Address:
PO BOX165
Provider Business Mailing Address City Name:
RAPID RIVER
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49878-9462
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
906-474-6010
Provider Business Mailing Address Fax Number:
906-474-6010

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1920 LAKE SHORE DR
Provider Second Line Business Practice Location Address:
MEMORIAL UNITED METHODIST CHURCH OFFICES
Provider Business Practice Location Address City Name:
GLADSTONE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49837-1249
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-420-5844
Provider Business Practice Location Address Fax Number:
906-474-6010
Provider Enumeration Date:
02/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DOUGHERTY
Authorized Official First Name:
ELEANOR
Authorized Official Middle Name:
LOUISE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
906-420-5844

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  6801069892 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1295715498 . This is a "OWNER / PROVIDER NPI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0P44870 . This is a "MEDICARE GROUP #" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0897996 . This is a "BCBSM INDIVIUAL PROVIDER PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 600073696 . This is a "MAGELLAN GROUP/ORG #" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8008979960 . This is a "BCBSM ID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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