Provider Demographics
NPI:1154583235
Name:PEDIATRIC COUNSELING CENTER, LLC
Entity type:Organization
Organization Name:PEDIATRIC COUNSELING CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JODI
Authorized Official - Middle Name:
Authorized Official - Last Name:TEN BROEKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-372-6500
Mailing Address - Street 1:950 N 10TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-6112
Mailing Address - Country:US
Mailing Address - Phone:269-372-6500
Mailing Address - Fax:269-372-6503
Practice Address - Street 1:950 N 10TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-6112
Practice Address - Country:US
Practice Address - Phone:269-372-6500
Practice Address - Fax:269-372-6503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010817251041C0700X
235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty