MEDICARE: PSYCH TO SITE WELLNESS PROGRAM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1215374558
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PSYCH TO SITE WELLNESS PROGRAM

Provider Business Mailing Address
First Line	:	28440 SOUTHFIELD RD
Second Line	:
City	:	LATHRUP VILLAGE
State	:	MI
Zip	:	48076-2820
Country	:	US
Telephone Number	:	248-557-4420
Fax Number	:

Provider Business Practice Location Address
First Line	:	28440 SOUTHFIELD RD
Second Line	:
City	:	LATHRUP VILLAGE
State	:	MI
Zip	:	48076-2820
Country	:	US
Telephone Number	:	248-557-4420
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	NELISSA NASH
Credential	:
Telephone Number	:	248-686-4926

Provider Enumeration Date	:	05/28/2013
Last Update Date	:	05/28/2013

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