Healthcare Provider Details

I. General information

NPI: 1073753323
Provider Name (Legal Business Name): GERIATRIC PSYCHIATRIC SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2009
Last Update Date: 07/25/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9465 COUNSELORS ROW SUITE 200
INDIANAPOLIS IN
46240-6423
US

IV. Provider business mailing address

39465 W 14 MILE RD
NOVI MI
48377-1600
US

V. Phone/Fax

Practice location:
  • Phone: 586-620-8100
  • 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 Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

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