Healthcare Provider Details

I. General information

NPI: 1295456366
Provider Name (Legal Business Name): RISING UP PSYCHOLOGICAL SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2022
Last Update Date: 09/07/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 W WASHINGTON ST STE D
MARQUETTE MI
49855-4367
US

IV. Provider business mailing address

2202 FITCH AVE
MARQUETTE MI
49855-1704
US

V. Phone/Fax

Practice location:
  • Phone: 906-869-8003
  • Fax:
Mailing address:
  • Phone: 906-869-8003
  • 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
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. EMILY ELIZABETH DEPETRO
Title or Position: CLINICAL PSYCHOLOGIST
Credential: PSYD
Phone: 906-869-8003