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General NPI Number Information
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NPI Number | 1609095702
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Entity Type | Organization
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Legal Business Name | PEBBLE CREEK COUNSELING LLC
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Dates
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Enumeration Date | 04/25/2007
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Last Update Date | 12/17/2008
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Provider Practice Location Address
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Address Line | 710 N MEAD ST
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City | SAINT JOHNS
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State | MI
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Zip | 48879-1332
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Country | US
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Telephone | 989-224-4110
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Fax |
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Provider Business Mailing Address
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Address Line | 710 N MEAD ST
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City | SAINT JOHNS
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State | MI
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Zip | 48879-1332
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Country | US
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Telephone | 989-224-4110
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Fax |
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Authorized Official
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Title or Position | STAFF PSYCHOLOGIST
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Name | DR. ELIZABETH ANN OLSON
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Credential | ED.D.
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Telephone | 989-224-4110
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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 | 6301007036
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License Number State | MI
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