Healthcare Provider Details

I. General information

NPI: 1992660005
Provider Name (Legal Business Name): PINE RIVER PSYCHOLOGICAL SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2025
Last Update Date: 12/20/2025
Certification Date: 12/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 BRIDGE ST
CHARLEVOIX MI
49720-1400
US

IV. Provider business mailing address

4053 OLD 31 S
CHARLEVOIX MI
49720-9691
US

V. Phone/Fax

Practice location:
  • Phone: 650-387-3927
  • Fax:
Mailing address:
  • Phone: 650-387-3927
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL DI MARTINO
Title or Position: MANAGING MEMBER
Credential: PSY.D.
Phone: 650-387-3927