Provider Demographics
NPI:1558831693
Name:GREAT LAKES COUNSELING AND WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:GREAT LAKES COUNSELING AND WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JODIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-488-0136
Mailing Address - Street 1:5364 N ELK ST
Mailing Address - Street 2:
Mailing Address - City:PECK
Mailing Address - State:MI
Mailing Address - Zip Code:48466-9677
Mailing Address - Country:US
Mailing Address - Phone:810-488-0136
Mailing Address - Fax:
Practice Address - Street 1:5364 N ELK ST
Practice Address - Street 2:
Practice Address - City:PECK
Practice Address - State:MI
Practice Address - Zip Code:48466-9677
Practice Address - Country:US
Practice Address - Phone:810-488-0136
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-02
Last Update Date:2018-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty