Provider Demographics
NPI:1831666288
Name:PETOSKEY PSYCHOLOGICAL HEALTH AND WELLNESS, PLLC
Entity Type:Organization
Organization Name:PETOSKEY PSYCHOLOGICAL HEALTH AND WELLNESS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:231-340-9113
Mailing Address - Street 1:PO BOX 133
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-0133
Mailing Address - Country:US
Mailing Address - Phone:231-340-9113
Mailing Address - Fax:231-347-5194
Practice Address - Street 1:560 W MITCHELL ST STE 208
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2278
Practice Address - Country:US
Practice Address - Phone:231-340-9113
Practice Address - Fax:231-347-5194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-24
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health