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General NPI Number Information
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NPI Number | 1861876468
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Entity Type | Organization
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Legal Business Name | GEODES, ANXIETY AND TRAUMA CLINIC, LLC
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Dates
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Enumeration Date | 07/13/2015
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Last Update Date | 08/11/2015
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Provider Practice Location Address
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Address Line | 1164 JAMES SAVAGE RD STE E
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City | MIDLAND
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State | MI
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Zip | 48640-6843
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Country | US
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Telephone | 989-513-5107
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Fax | 855-483-9638
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Provider Business Mailing Address
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Address Line | 1164 JAMES SAVAGE RD STE E
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City | MIDLAND
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State | MI
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Zip | 48640-6843
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Country | US
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Telephone | 989-513-5107
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Fax | 855-483-9638
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Authorized Official
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Title or Position | OWNER, CLINICAL SOCIAL WORKER
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Name | NICOLE LYNETTE BOURLAKAS-MAURER
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Credential | LMSW, CBIS
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Telephone | 989-513-5107
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 6801085334
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License Number State | MI
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