Healthcare Provider Details

I. General information

NPI: 1659030591
Provider Name (Legal Business Name): SUPPORTIVE CARE OF MICHIGAN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2021
Last Update Date: 12/08/2021
Certification Date: 12/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 LINCOLN AVE
IRON RIVER MI
49935-8452
US

IV. Provider business mailing address

27 RANDOLPH RD
HOWELL NJ
07731-8611
US

V. Phone/Fax

Practice location:
  • Phone: 718-298-2753
  • Fax:
Mailing address:
  • Phone: 718-298-2753
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: RAPHAEL LICHTSCHEIN
Title or Position: PRESIDENT
Credential:
Phone: 718-298-4375