Healthcare Provider Details

I. General information

NPI: 1851501761
Provider Name (Legal Business Name): PSYCHOLOGICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 07/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 S 4TH ST
STURGIS MI
49091-1819
US

IV. Provider business mailing address

103 S 4TH ST
STURGIS MI
49091-1819
US

V. Phone/Fax

Practice location:
  • Phone: 269-651-3902
  • Fax: 269-659-4874
Mailing address:
  • Phone: 269-651-3902
  • Fax: 269-659-4874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: DR. ROBERT GRAY PERRA
Title or Position: OWNER PSYCHOLOGIST
Credential: EDD
Phone: 269-651-3902