Provider Demographics
NPI:1780971606
Name:OLD BAT INC
Entity type:Organization
Organization Name:OLD BAT INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:LOVE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:734-218-6644
Mailing Address - Street 1:623 W HURON ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-6712
Mailing Address - Country:US
Mailing Address - Phone:734-218-6644
Mailing Address - Fax:734-956-5256
Practice Address - Street 1:623 W HURON ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-6712
Practice Address - Country:US
Practice Address - Phone:734-218-6644
Practice Address - Fax:734-956-5256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-29
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011905103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0H10564OtherBCBS IND PIN UNDER OBI
MI0H10569OtherBCBS PIN
MI1386684157OtherINDIVIDUAL NPI
MI1386684157OtherINDIVIDUAL NPI