Provider Demographics
NPI:1750659249
Name:OLD TOWN PSYCHOLOGICAL SERVICES-GAYLORD
Entity type:Organization
Organization Name:OLD TOWN PSYCHOLOGICAL SERVICES-GAYLORD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:989-448-8344
Mailing Address - Street 1:512 S UNION ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-3247
Mailing Address - Country:US
Mailing Address - Phone:231-941-6550
Mailing Address - Fax:231-941-8981
Practice Address - Street 1:128 N COURT AVE
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-1408
Practice Address - Country:US
Practice Address - Phone:989-448-8344
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OLD TOWN PSYCHOLOGICAL SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-12
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty