Provider Demographics
NPI:1710245261
Name:SOUTHPOINTE COUNSELING SERVICES
Entity Type:Organization
Organization Name:SOUTHPOINTE COUNSELING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:GORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MALLP
Authorized Official - Phone:734-365-4119
Mailing Address - Street 1:1927 EUREKA
Mailing Address - Street 2:
Mailing Address - City:WYANDOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48192
Mailing Address - Country:US
Mailing Address - Phone:734-365-4119
Mailing Address - Fax:734-281-0188
Practice Address - Street 1:1927 EUREKA RD
Practice Address - Street 2:
Practice Address - City:WYANDOTTE
Practice Address - State:MI
Practice Address - Zip Code:48192-6009
Practice Address - Country:US
Practice Address - Phone:734-365-4119
Practice Address - Fax:734-281-0188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-02
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301005878251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6301005878Medicaid