Provider Demographics
NPI:1215374558
Name:PSYCH TO SITE WELLNESS PROGRAM
Entity Type:Organization
Organization Name:PSYCH TO SITE WELLNESS PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:NASH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-686-4926
Mailing Address - Street 1:28440 SOUTHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:LATHRUP VILLAGE
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2820
Mailing Address - Country:US
Mailing Address - Phone:248-557-4420
Mailing Address - Fax:
Practice Address - Street 1:28440 SOUTHFIELD RD
Practice Address - Street 2:
Practice Address - City:LATHRUP VILLAGE
Practice Address - State:MI
Practice Address - Zip Code:48076-2820
Practice Address - Country:US
Practice Address - Phone:248-557-4420
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-28
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty