Healthcare Provider Details

I. General information

NPI: 1366931453
Provider Name (Legal Business Name): THIRD COAST CENTER FOR EMOTIONAL WELLNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2018
Last Update Date: 05/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

733 E 8TH ST STE 204
TRAVERSE CITY MI
49686-2665
US

IV. Provider business mailing address

1601 E 8TH ST
TRAVERSE CITY MI
49686-2923
US

V. Phone/Fax

Practice location:
  • Phone: 231-753-3134
  • Fax:
Mailing address:
  • Phone: 231-632-0814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number6401015285
License Number StateMI

VIII. Authorized Official

Name: JAKOB ROSSI
Title or Position: OWNER
Credential: LPC
Phone: 231-632-0814