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General NPI Number Information
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NPI Number | 1215067608
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Entity Type | Organization
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Legal Business Name | NEW CREATION PSYCHOLOGICAL SERVIES
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Dates
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Enumeration Date | 03/06/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 17635 PEARL ST
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City | BAILEY
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State | MI
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Zip | 49303-9750
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Country | US
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Telephone | 231-343-7969
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Fax |
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Provider Business Mailing Address
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Address Line | 7800 S RIVER RIDGE RD
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City | NEWAYGO
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State | MI
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Zip | 49337-9752
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Country | US
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Telephone | 231-652-1299
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Fax |
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Authorized Official
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Title or Position | PRESIDENT PSYCHOLOGIST
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Name | CARMEN COLLEEN BALDUS
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Credential | ED.D.
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Telephone | 231-652-1299
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 6301011963
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License Number State | MI
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