Provider Demographics
NPI:1124357488
Name:LIST PSYCHOLOGICAL SERVICES
Entity Type:Organization
Organization Name:LIST PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:R
Authorized Official - Last Name:LIST
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:989-672-6160
Mailing Address - Street 1:443 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:CARO
Mailing Address - State:MI
Mailing Address - Zip Code:48723-1539
Mailing Address - Country:US
Mailing Address - Phone:989-672-6160
Mailing Address - Fax:989-672-5649
Practice Address - Street 1:1600 N MICHIGAN AVE
Practice Address - Street 2:ROOM 506
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-5306
Practice Address - Country:US
Practice Address - Phone:989-758-3720
Practice Address - Fax:989-758-3760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-16
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YM0800X, 101YP2500X, 103TC0700X, 104100000X, 1041C0700X, 106H00000X
MI101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI034530OtherVALUE OPTIONS
MI034530OtherVALUE OPTIONS
MI0G96288Medicare UPIN