=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841252186
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PSYCH SERVICES, LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2006
-----------------------------------------------------
Last Update Date | 11/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2132 CEDAR ST STE 2
-----------------------------------------------------
City | HOLT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48842-1458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-853-1925
-----------------------------------------------------
Fax | 517-853-1926
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 809 CENTER STREET SUITE 8A
-----------------------------------------------------
City | LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-853-1925
-----------------------------------------------------
Fax | 517-853-1926
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR/ PRIMARY OFFICER
-----------------------------------------------------
Name | EDWARD C COOK
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 517-853-1925
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TF0200X
-----------------------------------------------------
Taxonomy Name | Forensic Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number | 6301005619
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------