Provider Demographics
NPI:1972359057
Name:GREAT LAKES WELLNESS GROUP
Entity type:Organization
Organization Name:GREAT LAKES WELLNESS GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SIERRA
Authorized Official - Middle Name:C
Authorized Official - Last Name:HILLEBRAND
Authorized Official - Suffix:
Authorized Official - Credentials:LLP
Authorized Official - Phone:734-330-3494
Mailing Address - Street 1:231 LITTLE LAKE DR STE B
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-6247
Mailing Address - Country:US
Mailing Address - Phone:734-249-8500
Mailing Address - Fax:
Practice Address - Street 1:231 LITTLE LAKE DR STE B
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-6247
Practice Address - Country:US
Practice Address - Phone:734-249-8500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-29
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No374J00000XNursing Service Related ProvidersDoulaGroup - Multi-Specialty