Provider Demographics
NPI:1992336457
Name:GREAT LAKES COMPREHENSIVE PSYCHOLOGICAL SERVICES
Entity type:Organization
Organization Name:GREAT LAKES COMPREHENSIVE PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARHTA CATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:CSW
Authorized Official - Phone:517-783-4418
Mailing Address - Street 1:1200 N WEST AVE STE 812
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-2180
Mailing Address - Country:US
Mailing Address - Phone:517-783-4418
Mailing Address - Fax:517-783-4504
Practice Address - Street 1:1200 N WEST AVE STE 812
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-2180
Practice Address - Country:US
Practice Address - Phone:517-783-4418
Practice Address - Fax:517-783-4504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-03
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty