Provider Demographics
NPI:1386963940
Name:PSYCHOLOGICAL WELLNESS, PLC
Entity type:Organization
Organization Name:PSYCHOLOGICAL WELLNESS, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BLOHM
Authorized Official - Suffix:
Authorized Official - Credentials:PHD,MSW
Authorized Official - Phone:517-242-1209
Mailing Address - Street 1:3721 W MICHIGAN AVE
Mailing Address - Street 2:301A
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-3693
Mailing Address - Country:US
Mailing Address - Phone:517-242-1209
Mailing Address - Fax:517-321-2296
Practice Address - Street 1:3721 W MICHIGAN AVE
Practice Address - Street 2:301A
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-3693
Practice Address - Country:US
Practice Address - Phone:517-242-1209
Practice Address - Fax:517-321-2296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-21
Last Update Date:2010-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010616721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P50770Medicare UPIN