1619007051 NPI number — NEUROLOGY NORTH, P.C.

Table of content: MS. STACEY PESCHEL SHERMAN LMSW, BCBA (NPI 1245522465)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619007051 NPI number — NEUROLOGY NORTH, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEUROLOGY NORTH, 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:
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:
1619007051
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
560 W MITCHELL ST
Provider Second Line Business Mailing Address:
SUITE 350
Provider Business Mailing Address City Name:
PETOSKEY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49770-2275
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-487-2220
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
560 W MITCHELL ST
Provider Second Line Business Practice Location Address:
SUITE 350
Provider Business Practice Location Address City Name:
PETOSKEY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49770-2275
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-487-2220
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ROTH
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
B
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
231-487-2220

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  4301046012 , 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)





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