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General NPI Number Information
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NPI Number | 1033318340
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Entity Type | Organization
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Legal Business Name | MIDWEST MICHIGAN PSYCHOLOGICAL ASSOCIATES, PLLC
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Dates
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Enumeration Date | 07/16/2007
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Last Update Date | 07/16/2007
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Provider Practice Location Address
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Address Line | 811 SUNNYSIDE DR SUITE I
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City | CADILLAC
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State | MI
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Zip | 49601-7002
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Country | US
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Telephone | 231-878-3059
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Fax | 866-217-1182
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Provider Business Mailing Address
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Address Line | 811 SUNNYSIDE DR SUITE I
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City | CADILLAC
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State | MI
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Zip | 49601-7002
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Country | US
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Telephone | 231-878-3059
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Fax | 866-217-1182
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | DR. CRAIG ALLEN DERROR
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Credential | PHD
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Telephone | 231-878-3059
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 6401004326
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 6301013463
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License Number State | MI
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