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General NPI Number Information
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NPI Number | 1912480518
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Entity Type | Organization
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Legal Business Name | GRAND TRAVERSE ASSESSMENT AND THERAPY, PLLC
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Dates
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Enumeration Date | 09/10/2018
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Last Update Date | 01/28/2019
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Provider Practice Location Address
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Address Line | 5123 N ROYAL DR
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City | TRAVERSE CITY
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State | MI
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Zip | 49684-9201
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Country | US
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Telephone | 517-887-9801
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Fax |
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Provider Business Mailing Address
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Address Line | 5123 N ROYAL DR
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City | TRAVERSE CITY
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State | MI
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Zip | 49684-9201
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CO-MANAGER
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Name | ROBERT FABIANO
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Credential | PHD
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Telephone | 517-243-7027
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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