Provider Demographics
NPI:1255923991
Name:MICHELLE PETZ LLC
Entity type:Organization
Organization Name:MICHELLE PETZ LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:RENE
Authorized Official - Last Name:PETZ
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:231-519-7555
Mailing Address - Street 1:25 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:MI
Mailing Address - Zip Code:49412-1186
Mailing Address - Country:US
Mailing Address - Phone:231-202-2772
Mailing Address - Fax:
Practice Address - Street 1:25 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:MI
Practice Address - Zip Code:49412-1186
Practice Address - Country:US
Practice Address - Phone:231-202-2772
Practice Address - Fax:231-486-5719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-04
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty