Provider Demographics
NPI:1376682641
Name:MID-AMERICA PSYCHOLOGICAL SERVICES PC
Entity Type:Organization
Organization Name:MID-AMERICA PSYCHOLOGICAL SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:LAVANNE
Authorized Official - Last Name:OGILVIE
Authorized Official - Suffix:
Authorized Official - Credentials:LLP
Authorized Official - Phone:269-373-8878
Mailing Address - Street 1:PO BOX 2585
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49081-2585
Mailing Address - Country:US
Mailing Address - Phone:269-373-8878
Mailing Address - Fax:269-373-4720
Practice Address - Street 1:8036 MOORS BRIDGE RD
Practice Address - Street 2:SUITE 2
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-4419
Practice Address - Country:US
Practice Address - Phone:269-327-1438
Practice Address - Fax:269-327-6454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0718001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0C96200Medicare ID - Type Unspecified