Healthcare Provider Details

I. General information

NPI: 1134652498
Provider Name (Legal Business Name): GREAT LAKES BAY HEALTH CENTERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2017
Last Update Date: 04/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4250 PLYMOUTH RD
ANN ARBOR MI
48109-2700
US

IV. Provider business mailing address

501 LAPEER AVE
SAGINAW MI
48607-1203
US

V. Phone/Fax

Practice location:
  • Phone: 989-759-6464
  • Fax: 989-399-8233
Mailing address:
  • Phone: 989-759-6464
  • Fax: 989-399-8233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DAWN CHRISTIAN
Title or Position: PROVIDER ENROLLMENT
Credential:
Phone: 989-759-6464