Provider Demographics
NPI:1235465659
Name:GERIATRIC PSYCHIATRIC SERVICES PLLC
Entity Type:Organization
Organization Name:GERIATRIC PSYCHIATRIC SERVICES PLLC
Other - Org Name:PSYCHOLOGIST GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEMENTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-619-9771
Mailing Address - Street 1:30781 STEPHENSON HWY
Mailing Address - Street 2:
Mailing Address - City:MADISON HTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-1618
Mailing Address - Country:US
Mailing Address - Phone:248-583-8922
Mailing Address - Fax:248-583-8969
Practice Address - Street 1:2024 ADDERBURY LN
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53711-4002
Practice Address - Country:US
Practice Address - Phone:734-883-3021
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GERIATRIC PSYCHIATRIC SERVICES PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-10-20
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty