Provider Demographics
NPI:1861876468
Name:GEODES, ANXIETY AND TRAUMA CLINIC, LLC
Entity type:Organization
Organization Name:GEODES, ANXIETY AND TRAUMA CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:LYNETTE
Authorized Official - Last Name:BOURLAKAS-MAURER
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW, CBIS
Authorized Official - Phone:989-513-5107
Mailing Address - Street 1:1164 JAMES SAVAGE RD STE E
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-6843
Mailing Address - Country:US
Mailing Address - Phone:989-513-5107
Mailing Address - Fax:855-483-9638
Practice Address - Street 1:1164 JAMES SAVAGE RD STE E
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-6843
Practice Address - Country:US
Practice Address - Phone:989-513-5107
Practice Address - Fax:855-483-9638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-13
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010853341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI730195Medicaid
MI0G36205030Medicare PIN