Healthcare Provider Details

I. General information

NPI: 1376359364
Provider Name (Legal Business Name): GARRETT MICHAEL BRYAN BEHAVIOR TECH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MR. GARRETT MICHAEL POLHAMUS

II. Dates (important events)

Enumeration Date: 12/05/2024
Last Update Date: 02/24/2025
Certification Date: 02/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 W NORTH ST
JACKSON MI
49202-3132
US

IV. Provider business mailing address

2400 SCIENCE PKWY
OKEMOS MI
48864-2560
US

V. Phone/Fax

Practice location:
  • Phone: 517-513-3297
  • Fax:
Mailing address:
  • Phone: 517-374-8066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: