Healthcare Provider Details

I. General information

NPI: 1811884976
Provider Name (Legal Business Name): LAKE MICHIGAN PSYCHOLOGICAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2025
Last Update Date: 06/20/2025
Certification Date: 06/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 W FRONT ST STE 150B
TRAVERSE CITY MI
49684-2265
US

IV. Provider business mailing address

440 W FRONT ST STE 150B
TRAVERSE CITY MI
49684-2265
US

V. Phone/Fax

Practice location:
  • Phone: 231-492-0718
  • Fax:
Mailing address:
  • Phone: 231-492-0718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MR. KYLE R BYRNES
Title or Position: PRESEDENT
Credential: LLP
Phone: 586-601-5495