Healthcare Provider Details

I. General information

NPI: 1174381974
Provider Name (Legal Business Name): TRAUMA AND ADDICTION SOLUTIONS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2024
Last Update Date: 03/11/2024
Certification Date: 03/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 N PINE RIVER ST
ITHACA MI
48847-1039
US

IV. Provider business mailing address

1551 N FERRIS RD
SUMNER MI
48889-8718
US

V. Phone/Fax

Practice location:
  • Phone: 989-287-0662
  • Fax:
Mailing address:
  • Phone: 989-287-0662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW STACK
Title or Position: OWNER
Credential: MD
Phone: 989-287-0662