=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396585840
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REAL LIFE COUNSELING OF NORTHERN MICHIGAN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2024
-----------------------------------------------------
Last Update Date | 11/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1982 E. MITCHELL RD.
-----------------------------------------------------
City | PETOSKEY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49770
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-622-5800
-----------------------------------------------------
Fax | 231-272-5721
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1982 E. MITCHELL RD.
-----------------------------------------------------
City | PETOSKEY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49770
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-622-5800
-----------------------------------------------------
Fax | 231-272-5721
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COUNSELOR
-----------------------------------------------------
Name | JAKE TRACY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 231-622-5800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------