1093069734 NPI number — GREAT LAKES THERAPY HOUSECALLS, P.C.

Table of content: (NPI 1093069734)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093069734 NPI number — GREAT LAKES THERAPY HOUSECALLS, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREAT LAKES THERAPY HOUSECALLS, P.C.
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:
6
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:
1093069734
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/09/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3281 RACQUET CLUB DR UNIT A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TRAVERSE CITY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49684-4701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-941-8100
Provider Business Mailing Address Fax Number:
231-941-8812

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9731 E CHERRY BEND RD
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
TRAVERSE CITY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49684-7621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-941-8100
Provider Business Practice Location Address Fax Number:
231-995-9297
Provider Enumeration Date:
11/02/2012

Additional Information

Authorized Official

Authorized Official Last Name:
HARVEY
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT / ADMINISTRATOR
Authorized Official Telephone Number:
231-941-8100

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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