Healthcare Provider Details

I. General information

NPI: 1851987473
Provider Name (Legal Business Name): PROFESSIONAL PSYCHOTHERAPY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2020
Last Update Date: 12/17/2020
Certification Date: 12/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 HART ST
MARSHALL MI
49068-1824
US

IV. Provider business mailing address

PO BOX 10
MASON MI
48854-0010
US

V. Phone/Fax

Practice location:
  • Phone: 517-227-0475
  • Fax:
Mailing address:
  • Phone: 517-676-9788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name: MARYBETH HOUPT
Title or Position: CREDENTIALING
Credential:
Phone: 517-676-9788