Provider Demographics
NPI:1225150139
Name:MERIDIAN PROFESSIONAL PSYCHOLOGICAL CONSULTANTS
Entity Type:Organization
Organization Name:MERIDIAN PROFESSIONAL PSYCHOLOGICAL CONSULTANTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MRS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:GUNNINGS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD LAC
Authorized Official - Phone:517-332-0811
Mailing Address - Street 1:5031 PARK LAKE ROAD
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-3835
Mailing Address - Country:US
Mailing Address - Phone:517-332-0811
Mailing Address - Fax:517-332-4452
Practice Address - Street 1:5031 PARK LAKE ROAD
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-3835
Practice Address - Country:US
Practice Address - Phone:517-332-0811
Practice Address - Fax:517-332-4452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2084P0800X
MI330070324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Not Answered324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI248226OtherCORPORATION
MI3276326Medicaid
20486OtherBLUE CROSS SUB ABUSE
037146OtherVALUE OPTIONS
MI3276326Medicaid