Provider Demographics
NPI:1487712642
Name:BAY PSYCHOLOGICAL SERVICES
Entity type:Organization
Organization Name:BAY PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:J
Authorized Official - Last Name:SOWLE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:231-946-6488
Mailing Address - Street 1:PO BOX 4249
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49685-4249
Mailing Address - Country:US
Mailing Address - Phone:231-946-6488
Mailing Address - Fax:231-275-0153
Practice Address - Street 1:236 1/2 E FRONT ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2526
Practice Address - Country:US
Practice Address - Phone:231-946-6488
Practice Address - Fax:231-275-0153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007636103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P37840Medicare PIN