Healthcare Provider Details

I. General information

NPI: 1538973144
Provider Name (Legal Business Name): CLINTON COUNTY MEDICAL CENTER PSYCHOLOGICAL SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2025
Last Update Date: 02/07/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 WATERFORD PKWY
SAINT JOHNS MI
48879-9630
US

IV. Provider business mailing address

1505 WATERFORD PKWY
SAINT JOHNS MI
48879-9630
US

V. Phone/Fax

Practice location:
  • Phone: 989-292-3572
  • Fax: 989-292-3952
Mailing address:
  • Phone: 989-292-3572
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: BRAD ALLEN MESSENGER
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 989-292-3572