Provider Demographics
NPI:1154464907
Name:MIDWEST PSYCHOLOGY, PC
Entity Type:Organization
Organization Name:MIDWEST PSYCHOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GAILORD
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:WEEKS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:231-924-5309
Mailing Address - Street 1:905 S STEWART AVE
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:MI
Mailing Address - Zip Code:49412-9201
Mailing Address - Country:US
Mailing Address - Phone:231-924-5309
Mailing Address - Fax:231-924-1685
Practice Address - Street 1:905 S STEWART AVE
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:MI
Practice Address - Zip Code:49412-9201
Practice Address - Country:US
Practice Address - Phone:231-924-5309
Practice Address - Fax:231-924-1685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301003219103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M98450Medicare ID - Type Unspecified