Healthcare Provider Details

I. General information

NPI: 1316557523
Provider Name (Legal Business Name): TRI-CITIES DBT & TRAUMA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2020
Last Update Date: 08/03/2020
Certification Date: 08/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1807 SYLVAN LN
MIDLAND MI
48640-6760
US

IV. Provider business mailing address

240 W MAIN ST STE 2600
MIDLAND MI
48640-5191
US

V. Phone/Fax

Practice location:
  • Phone: 989-906-0433
  • Fax:
Mailing address:
  • Phone: 989-906-0433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name: MRS. SARA GRACE KNUTSON
Title or Position: MENTAL HEALTH COUNSELOR
Credential: LPC
Phone: 989-906-0433