Healthcare Provider Details

I. General information

NPI: 1104717941
Provider Name (Legal Business Name): CONVERGENCE PSYCHOLOGICAL PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2025
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4604 N SAGINAW RD STE L
MIDLAND MI
48640-2394
US

IV. Provider business mailing address

4604 N SAGINAW RD
MIDLAND MI
48640-2387
US

V. Phone/Fax

Practice location:
  • Phone: 989-817-2905
  • Fax: 810-777-7660
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: ETHAN VOLMERING
Title or Position: ADMINISTRATIVE SPECIALIST
Credential:
Phone: 989-817-2905