=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376682641
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MID-AMERICA PSYCHOLOGICAL SERVICES, P. C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2007
-----------------------------------------------------
Last Update Date | 09/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8036 MOORS BRIDGE RD SUITE 2
-----------------------------------------------------
City | PORTAGE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49024-4419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-327-1438
-----------------------------------------------------
Fax | 269-327-6454
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8036 MOORSBRIDGE RD SUITE 2
-----------------------------------------------------
City | PORTAGE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-327-1438
-----------------------------------------------------
Fax | 269-327-6454
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | MR. CHARLES CLEARWATER
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 269-744-6138
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 071800
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------