Healthcare Provider Details

I. General information

NPI: 1184021834
Provider Name (Legal Business Name): PROFESSIONAL PSYCHOLOGICAL AND REHABILITATION SERVICES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2014
Last Update Date: 11/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 S WAVERLY RD
LANSING MI
48917-3631
US

IV. Provider business mailing address

302 S WAVERLY RD SUITE1
LANSING MI
48917-3631
US

V. Phone/Fax

Practice location:
  • Phone: 517-321-5900
  • Fax:
Mailing address:
  • Phone: 517-321-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number6401003899
License Number StateMI

VIII. Authorized Official

Name: JOHN P DOWLING
Title or Position: CLINICAL THERAPIST
Credential: MA, LPC.
Phone: 517-321-5900