Provider Demographics
NPI:1134341399
Name:MICHIGAN STATE UNIVERSITY PSYCHOLOGICAL CLINIC
Entity type:Organization
Organization Name:MICHIGAN STATE UNIVERSITY PSYCHOLOGICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:ELI
Authorized Official - Last Name:GREENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:517-355-9564
Mailing Address - Street 1:MICHIGAN STATE UNIVERSITY PSYCHOLOGICAL CLINIC
Mailing Address - Street 2:151 PSYCHOLOGY BUILDING
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-1116
Mailing Address - Country:US
Mailing Address - Phone:517-355-9564
Mailing Address - Fax:517-353-5437
Practice Address - Street 1:MICHIGAN STATE UNIVERSITY PSYCHOLOGICAL CLINIC
Practice Address - Street 2:151 PSYCHOLOGY BUILDING
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48824-1116
Practice Address - Country:US
Practice Address - Phone:517-355-9564
Practice Address - Fax:517-353-5437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007903261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)