Provider Demographics
NPI:1922389477
Name:GRAND BLANC THERAPY
Entity Type:Organization
Organization Name:GRAND BLANC THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YVONNE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAKIDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-659-7242
Mailing Address - Street 1:8323 OFFICE PARK DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-2068
Mailing Address - Country:US
Mailing Address - Phone:810-659-7242
Mailing Address - Fax:810-953-3116
Practice Address - Street 1:8323 OFFICE PARK DR
Practice Address - Street 2:SUITE B
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-2068
Practice Address - Country:US
Practice Address - Phone:810-659-7242
Practice Address - Fax:810-953-3116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-29
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801085260104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty