=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952932824
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POLARIS PSYCHOTHERAPY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2020
-----------------------------------------------------
Last Update Date | 01/30/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 N HURON ST
-----------------------------------------------------
City | YPSILANTI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48197-2610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-205-3305
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 120 N HURON ST
-----------------------------------------------------
City | YPSILANTI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48197-2610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-470-8243
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | BREANNA GREER
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 269-470-8243
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------