1720024672 NPI number — SHEPHERDS STAFF COUNSELING SERVICES, PLLC

Table of content: (NPI 1720024672)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720024672 NPI number — SHEPHERDS STAFF COUNSELING SERVICES, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHEPHERDS STAFF COUNSELING SERVICES, 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:
1720024672
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/25/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3887 OKEMOS RD
Provider Second Line Business Mailing Address:
SUITE A2
Provider Business Mailing Address City Name:
OKEMOS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48864-3664
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-333-6700
Provider Business Mailing Address Fax Number:
517-347-3702

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3887 OKEMOS RD
Provider Second Line Business Practice Location Address:
SUITE A2
Provider Business Practice Location Address City Name:
OKEMOS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48864-3664
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-333-6700
Provider Business Practice Location Address Fax Number:
517-347-3702
Provider Enumeration Date:
06/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LUCAS
Authorized Official First Name:
CAROLYN
Authorized Official Middle Name:
SUE
Authorized Official Title or Position:
PSYCHOLOGIST, OWNER
Authorized Official Telephone Number:
517-333-6700

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  6301008781 , 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: 044627 . This is a "BEHAVIORAL HEALTH ADMINIS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0C33276 . This is a "BLUE CROSS BLUE SHIELD PR" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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