MEDICARE: LIST PSYCHOLOGICAL SERVICES, PLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	101Y00000X	Counselor
2	101YA0400X	Addiction (Substance Use Disorder) Counselor
3	101YP2500X	Professional Counselor
4	103TC0700X	Clinical Psychologist
5	106H00000X	Marriage & Family Therapist
6	2084P0800X	Psychiatry Physician
7	2084P0802X	Addiction Psychiatry Physician
8	1041C0700X	Clinical Social Worker

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	NA	OTHER		NA

General Provider Information

NPI Number	:	1174267116
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIST PSYCHOLOGICAL SERVICES, PLC

Provider Business Mailing Address
First Line	:	443 N STATE ST
Second Line	:
City	:	CARO
State	:	MI
Zip	:	48723-1539
Country	:	US
Telephone Number	:	989-672-6160
Fax Number	:

Provider Business Practice Location Address
First Line	:	33 W SANILAC RD
Second Line	:
City	:	SANDUSKY
State	:	MI
Zip	:	48471-1036
Country	:	US
Telephone Number	:	810-667-4500
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	JACQUELINE DIANE LIST
Credential	:
Telephone Number	:	989-672-6160

Provider Enumeration Date	:	04/26/2022
Last Update Date	:	05/23/2025

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