Provider Demographics
NPI:1588841787
Name:TREESIDE PSYCHOLOGICAL CLINIC P.C.
Entity Type:Organization
Organization Name:TREESIDE PSYCHOLOGICAL CLINIC P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:B
Authorized Official - Last Name:ROWE
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:248-693-9614
Mailing Address - Street 1:486 TANVIEW DR
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48371-4761
Mailing Address - Country:US
Mailing Address - Phone:248-693-9614
Mailing Address - Fax:248-693-9615
Practice Address - Street 1:45 N LAPEER ST
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48362-3159
Practice Address - Country:US
Practice Address - Phone:248-693-9614
Practice Address - Fax:248-693-9615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-30
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 103TP2701X
MI68010724901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Single Specialty