Healthcare Provider Details

I. General information

NPI: 1124273826
Provider Name (Legal Business Name): GERIATRIC PSYCHIATRIC SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2008
Last Update Date: 07/25/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WESTBROOK CORP CTR SUITE 300
WESTCHESTER IL
60154-5701
US

IV. Provider business mailing address

39465 W 14 MILE RD
NOVI MI
48377-1600
US

V. Phone/Fax

Practice location:
  • Phone: 708-375-3075
  • Fax: 866-227-7418
Mailing address:
  • Phone: 877-906-9699
  • Fax: 888-483-0118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERT A CLEMENTE
Title or Position: ADMIN DIR.
Credential: ESQ.
Phone: 586-620-8100