Healthcare Provider Details

I. General information

NPI: 1992857338
Provider Name (Legal Business Name): LITTLE TRAVERSE PSYCHIATRIC ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 05/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2206 MITCHELL PARK DR STE 10
PETOSKEY MI
49770-8674
US

IV. Provider business mailing address

2206 MITCHELL PARK DR STE 10
PETOSKEY MI
49770-8674
US

V. Phone/Fax

Practice location:
  • Phone: 231-487-2415
  • Fax: 231-487-6569
Mailing address:
  • Phone: 231-487-2415
  • Fax: 231-487-6569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateMI

VIII. Authorized Official

Name: DR. ROBERT GEORGE FAWCETT
Title or Position: PRESIDENT
Credential: M.D.
Phone: 231-487-2415