Provider Demographics
NPI:1205205747
Name:GREAT LAKES PSYCHOLOGICAL ASSOCIATES PLLC
Entity Type:Organization
Organization Name:GREAT LAKES PSYCHOLOGICAL ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:ADAM
Authorized Official - Last Name:MOEGGENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:989-317-3188
Mailing Address - Street 1:400 S UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-3170
Mailing Address - Country:US
Mailing Address - Phone:989-317-3188
Mailing Address - Fax:989-202-1888
Practice Address - Street 1:400 S UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-3170
Practice Address - Country:US
Practice Address - Phone:989-317-3188
Practice Address - Fax:989-202-1888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-15
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014926103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty