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General NPI Number Information
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NPI Number | 1992660005
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Entity Type | Organization
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Legal Business Name | PINE RIVER PSYCHOLOGICAL SERVICES PLLC
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Dates
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Enumeration Date | 12/20/2025
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Last Update Date | 12/20/2025
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Provider Practice Location Address
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Address Line | 223 BRIDGE ST
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City | CHARLEVOIX
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State | MI
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Zip | 49720-1400
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Country | US
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Telephone | 650-387-3927
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Fax |
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Provider Business Mailing Address
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Address Line | 4053 OLD 31 S
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City | CHARLEVOIX
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State | MI
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Zip | 49720-9691
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Country | US
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Telephone | 650-387-3927
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | DR. MICHAEL DI MARTINO
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Credential | PSY.D.
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Telephone | 650-387-3927
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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