Healthcare Provider Details

I. General information

NPI: 1285038349
Provider Name (Legal Business Name): NORTHERN MICHIGAN PSYCHIATRIC SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2014
Last Update Date: 10/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3287 RACQUET CLUB DR UNIT A
TRAVERSE CITY MI
49684-4702
US

IV. Provider business mailing address

3287 RACQUET CLUB DR UNIT A
TRAVERSE CITY MI
49684-4702
US

V. Phone/Fax

Practice location:
  • Phone: 231-935-0355
  • Fax:
Mailing address:
  • Phone: 231-935-0355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberL2401958
License Number StateMI

VIII. Authorized Official

Name: SANDER WECKSTEIN
Title or Position: PHYSICIAN
Credential: MD
Phone: 231-935-0355