Provider Demographics
NPI:1083921787
Name:BOWLING GREEN STATE UNIVERSITY
Entity Type:Organization
Organization Name:BOWLING GREEN STATE UNIVERSITY
Other - Org Name:PSYCHOLOGICAL SERVICES CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:KELSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-372-2540
Mailing Address - Street 1:822 E MERRY STREET BOWLING GREEN STATE UNIVERSITY
Mailing Address - Street 2:300 PSYCHOLOGY BUILDING
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43403-0232
Mailing Address - Country:US
Mailing Address - Phone:419-372-2540
Mailing Address - Fax:419-372-2533
Practice Address - Street 1:822 E MERRY STREET BOWLING GREEN STATE UNIVERSITY
Practice Address - Street 2:300 PSYCHOLOGY BUILDING
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43403
Practice Address - Country:US
Practice Address - Phone:419-372-2540
Practice Address - Fax:419-372-2533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-02
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6697103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0747240Medicaid