Provider Demographics
NPI:1467773408
Name:GERIATRIC PSYCHIATRIC SERVICES
Entity type:Organization
Organization Name:GERIATRIC PSYCHIATRIC SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEMENTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-619-9771
Mailing Address - Street 1:1721 MOON LAKE BLVD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:HOFFMAN ESTATES
Mailing Address - State:IL
Mailing Address - Zip Code:60169-1069
Mailing Address - Country:US
Mailing Address - Phone:847-519-3650
Mailing Address - Fax:847-519-3652
Practice Address - Street 1:363 W BIG BEAVER RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-5220
Practice Address - Country:US
Practice Address - Phone:248-619-9771
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-14
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty