Provider Demographics
NPI:1619109501
Name:PREMIER PSYCHOLOGICAL SERVICES, PLLC
Entity Type:Organization
Organization Name:PREMIER PSYCHOLOGICAL SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:SANSOM
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:906-228-6200
Mailing Address - Street 1:1300 W RIDGE ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-3194
Mailing Address - Country:US
Mailing Address - Phone:906-228-6200
Mailing Address - Fax:906-228-6244
Practice Address - Street 1:1300 W RIDGE ST
Practice Address - Street 2:SUITE 2
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-3194
Practice Address - Country:US
Practice Address - Phone:906-228-6200
Practice Address - Fax:906-228-6244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-11
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301010832103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0E20205OtherBCBS PROVIDER
MI0E20193OtherBCBS