Provider Demographics
NPI:1952450108
Name:PEDIATRIC PSYCHOLOGICAL SERVICES PLLC
Entity Type:Organization
Organization Name:PEDIATRIC PSYCHOLOGICAL SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:WISDORF-HOUTKOOPER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:269-979-3881
Mailing Address - Street 1:5181 WALNUT RDG
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49017-9210
Mailing Address - Country:US
Mailing Address - Phone:269-979-3881
Mailing Address - Fax:269-979-2841
Practice Address - Street 1:714 MAIN ST
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49015-4568
Practice Address - Country:US
Practice Address - Phone:269-979-3881
Practice Address - Fax:269-979-2841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009191103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI19466Medicare UPIN
MI7000039921Medicare UPIN
MI51816127Medicare UPIN