Provider Demographics
NPI:1972625424
Name:PROFESSIONAL PSYCHOLOGICAL & REHABILITATION SERVICES
Entity Type:Organization
Organization Name:PROFESSIONAL PSYCHOLOGICAL & REHABILITATION SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:HILTON
Authorized Official - Middle Name:T
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:517-321-5900
Mailing Address - Street 1:3815 W ST JOSEPH HWY, SUITE A101
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917
Mailing Address - Country:US
Mailing Address - Phone:517-321-5900
Mailing Address - Fax:517-321-5945
Practice Address - Street 1:3815 W ST JOSEPH HWY, SUITE A101
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917
Practice Address - Country:US
Practice Address - Phone:517-321-5900
Practice Address - Fax:517-321-5945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301003971103TC0700X
MI68010634381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOC34604Medicaid