Provider Demographics
NPI:1649480674
Name:GREAT LAKES THERAPY HOUSE CALLS PC
Entity type:Organization
Organization Name:GREAT LAKES THERAPY HOUSE CALLS PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:HARVEY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:231-941-8100
Mailing Address - Street 1:1650 BARLOW ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-4721
Mailing Address - Country:US
Mailing Address - Phone:231-941-8100
Mailing Address - Fax:231-922-0382
Practice Address - Street 1:5123 N ROYAL DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-9201
Practice Address - Country:US
Practice Address - Phone:231-941-8100
Practice Address - Fax:231-941-8812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI670B8OtherBCBS MI
MI650B8OtherBCBS OF MI
MI0N83550Medicare PIN
MI670B8OtherBCBS MI