Healthcare Provider Details

I. General information

NPI: 1427393750
Provider Name (Legal Business Name): PSYCHOLOGY PROFESSIONALS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2012
Last Update Date: 11/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2519 NILES AVE
SAINT JOSEPH MI
49085-1936
US

IV. Provider business mailing address

2519 NILES AVE
SAINT JOSEPH MI
49085-1936
US

V. Phone/Fax

Practice location:
  • Phone: 269-277-6657
  • Fax:
Mailing address:
  • Phone: 269-277-6657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MR. RONALD K. PHILLIPS
Title or Position: OWNER
Credential: M.A.
Phone: 269-277-6657