Provider Demographics
NPI:1326357476
Name:FULL CIRCLE BEHAVIORAL SERVICES, PC
Entity Type:Organization
Organization Name:FULL CIRCLE BEHAVIORAL SERVICES, PC
Other - Org Name:FULL CIRCLE WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:LITTLE
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LLP
Authorized Official - Phone:248-722-2653
Mailing Address - Street 1:5600 W MAPLE RD STE A110
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3705
Mailing Address - Country:US
Mailing Address - Phone:248-722-2653
Mailing Address - Fax:248-855-4840
Practice Address - Street 1:5600 W MAPLE RD STE A110
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3705
Practice Address - Country:US
Practice Address - Phone:248-722-2653
Practice Address - Fax:248-855-4840
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FULL CIRCLE BEHAVIORAL HEALTH, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-10-06
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011714103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI-3622OtherMEDICARE PART B NUMBER