Provider Demographics
NPI:1992108872
Name:INTEGRATIVE PSYCHOTHERAPY, PLC
Entity type:Organization
Organization Name:INTEGRATIVE PSYCHOTHERAPY, PLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:WEIKS
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:616-822-9714
Mailing Address - Street 1:2707 BRETON RD SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-5633
Mailing Address - Country:US
Mailing Address - Phone:616-822-9714
Mailing Address - Fax:
Practice Address - Street 1:2707 BRETON RD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-5633
Practice Address - Country:US
Practice Address - Phone:616-822-9714
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-06
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301004073103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty