Provider Demographics
NPI:1609095702
Name:PEBBLE CREEK COUNSELING LLC
Entity Type:Organization
Organization Name:PEBBLE CREEK COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STAFF PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:989-224-4110
Mailing Address - Street 1:710 N MEAD ST
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:MI
Mailing Address - Zip Code:48879-1332
Mailing Address - Country:US
Mailing Address - Phone:989-224-4110
Mailing Address - Fax:
Practice Address - Street 1:710 N MEAD ST
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:MI
Practice Address - Zip Code:48879-1332
Practice Address - Country:US
Practice Address - Phone:989-224-4110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007036103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIR90621Medicare UPIN