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General NPI Number Information
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NPI Number | 1831666288
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Entity Type | Organization
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Legal Business Name | PETOSKEY PSYCHOLOGICAL HEALTH AND WELLNESS, PLLC
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Dates
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Enumeration Date | 10/24/2018
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Last Update Date | 04/22/2024
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Provider Practice Location Address
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Address Line | 2810 CHARLEVOIX RD STE 102
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City | PETOSKEY
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State | MI
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Zip | 49770-8421
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Country | US
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Telephone | 231-340-9113
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Fax | 231-642-9116
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Provider Business Mailing Address
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Address Line | PO BOX 133
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City | PETOSKEY
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State | MI
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Zip | 49770-0133
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Country | US
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Telephone | 231-340-9113
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Fax | 231-347-5194
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Authorized Official
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Title or Position | OWNER
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Name | DR. REBECCA ROTH
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Credential | PHD
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Telephone | 231-340-9113
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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