Provider Demographics
NPI:1609173921
Name:GREAT MINDS OF MICHIGAN PLLC
Entity Type:Organization
Organization Name:GREAT MINDS OF MICHIGAN PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER, DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JANET
Authorized Official - Middle Name:S
Authorized Official - Last Name:REED
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:586-913-1038
Mailing Address - Street 1:23210 GREATER MACK AVE
Mailing Address - Street 2:#216
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-3422
Mailing Address - Country:US
Mailing Address - Phone:586-913-1038
Mailing Address - Fax:586-773-3355
Practice Address - Street 1:200 DIVERSION ST
Practice Address - Street 2:SUITE 150
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-2267
Practice Address - Country:US
Practice Address - Phone:586-913-1038
Practice Address - Fax:586-773-3355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-23
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012828103G00000X, 103TC0700X, 103TC2200X, 103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIPHD888810Medicaid
MIJR012828OtherCHAMPUS-CHAMPUS
MIJR012828OtherCOMMERCIAL-COMMERCIAL
MIP42853Medicare PIN