Provider Demographics
NPI:1114715083
Name:GREAT LAKES PSYCHOTHERAPY LLC
Entity type:Organization
Organization Name:GREAT LAKES PSYCHOTHERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ISRAEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-318-1474
Mailing Address - Street 1:5640 W MAPLE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:W BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3717
Mailing Address - Country:US
Mailing Address - Phone:561-318-1474
Mailing Address - Fax:
Practice Address - Street 1:92 ERSKINE HILL
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:ENGLAND
Practice Address - Zip Code:NW11 6HR
Practice Address - Country:GB
Practice Address - Phone:561-318-1474
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-29
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)