Provider Demographics
NPI: | 1881644789 |
---|---|
Name: | LIST PSYCHOLOGICAL SERVICES, PLC |
Entity Type: | Organization |
Organization Name: | LIST PSYCHOLOGICAL SERVICES, PLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | COO |
Authorized Official - Prefix: | |
Authorized Official - First Name: | JACQUELINE |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | THOMPSON |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 989-672-6160 |
Mailing Address - Street 1: | 443 N STATE ST |
Mailing Address - Street 2: | |
Mailing Address - City: | CARO |
Mailing Address - State: | MI |
Mailing Address - Zip Code: | 48723-1539 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 989-672-6160 |
Mailing Address - Fax: | 989-672-6272 |
Practice Address - Street 1: | 651 N STATE ST |
Practice Address - Street 2: | |
Practice Address - City: | CARO |
Practice Address - State: | MI |
Practice Address - Zip Code: | 48723-1543 |
Practice Address - Country: | US |
Practice Address - Phone: | 989-673-5700 |
Practice Address - Fax: | 989-672-2555 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-05-11 |
Last Update Date: | 2016-12-27 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
101Y00000X, 101YA0400X, 101YM0800X, 101YP2500X, 103T00000X, 103TC0700X, 104100000X, 1041C0700X, 2084A0401X, 2084P0800X | ||
MI | SA0790015 | 261QM0801X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 261QM0801X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | |
No | 101Y00000X | Behavioral Health & Social Service Providers | Counselor | Group - Multi-Specialty | |
No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
No | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health | Group - Multi-Specialty |
No | 101YP2500X | Behavioral Health & Social Service Providers | Counselor | Professional | Group - Multi-Specialty |
No | 103T00000X | Behavioral Health & Social Service Providers | Psychologist | Group - Multi-Specialty | |
No | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical | Group - Multi-Specialty |
No | 104100000X | Behavioral Health & Social Service Providers | Social Worker | Group - Multi-Specialty | |
No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
No | 2084A0401X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Medicine | Group - Multi-Specialty |
No | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MI | 750910576 | Other | BCBS OF MICHIGAN |
MI | 034530 | Other | VALUE OPTIONS |
MI | 20556 | Other | BCBS SUBSTANCE ABUSE |
MI | 1006309 | Other | MCLAREN HEALTH ADVANTAGE |
MI | 0D41044 | Other | BCBS PSYCHIATRIST |
MI | B47048 | Medicare UPIN | |
MI | 1006309 | Other | MCLAREN HEALTH ADVANTAGE |
MI | 750910576 | Other | BCBS OF MICHIGAN |