Provider Demographics
NPI:1710397468
Name:TRAVERSE BAY COUNSELING & WELLNESS
Entity Type:Organization
Organization Name:TRAVERSE BAY COUNSELING & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:JACALYN
Authorized Official - Middle Name:
Authorized Official - Last Name:LASICH
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:231-735-2270
Mailing Address - Street 1:2177 HOLLAND CIR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49685-7945
Mailing Address - Country:US
Mailing Address - Phone:231-590-4716
Mailing Address - Fax:
Practice Address - Street 1:3301 VETERANS DR
Practice Address - Street 2:SUITE 124
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-4574
Practice Address - Country:US
Practice Address - Phone:231-735-2270
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-03
Last Update Date:2014-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801089753251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1487909396Medicaid
MI0961729OtherBCBSM PIN
MI0961729OtherBCBSM PIN