Provider Demographics
NPI:1194904029
Name:CAROLYN VAN CLEAVE, ED.D. PC
Entity type:Organization
Organization Name:CAROLYN VAN CLEAVE, ED.D. PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN CLEAVE
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:989-772-6241
Mailing Address - Street 1:901 CANAL ST
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-3304
Mailing Address - Country:US
Mailing Address - Phone:989-772-6241
Mailing Address - Fax:989-772-8009
Practice Address - Street 1:901 CANAL ST
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-3304
Practice Address - Country:US
Practice Address - Phone:989-772-6241
Practice Address - Fax:989-772-8009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-27
Last Update Date:2007-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301002777103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION91730Medicare PIN