Healthcare Provider Details

I. General information

NPI: 1073987616
Provider Name (Legal Business Name): CENTRAL MICHIGAN UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2015
Last Update Date: 11/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 HEALTH PROFESSIONS BLDG STE 2105
MT PLEASANT MI
48859-0001
US

IV. Provider business mailing address

1101 HEALTH PROFESSIONS BLDG STE 2105
MT PLEASANT MI
48859-0001
US

V. Phone/Fax

Practice location:
  • Phone: 989-774-3904
  • Fax: 989-774-1891
Mailing address:
  • Phone: 989-774-3904
  • Fax: 989-774-1891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: SHERYL SIAS
Title or Position: CREDENTIALING
Credential:
Phone: 989-774-2597