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	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1006309	OTHER	MI	MCLAREN HEALTH ADVANTAGE
2	034530	OTHER	MI	VALUE OPTIONS
3	750910965	OTHER	MI	BCBS OF MICHIGAN
4	0D41044	OTHER	MI	BCBS PSYCHIATRIST

General Provider Information

NPI Number	:	1306896956
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	:	989-672-5649

Provider Business Practice Location Address
First Line	:	624 W NEPESSING ST
Second Line	:	SUITE 300
City	:	LAPEER
State	:	MI
Zip	:	48446-2090
Country	:	US
Telephone Number	:	810-667-4500
Fax Number	:	810-667-4500

Authorized Official
Title or Position	:	COO
Name	:	JACQUELINE THOMPSON
Credential	:
Telephone Number	:	989-672-6160

Provider Enumeration Date	:	05/12/2006
Last Update Date	:	12/27/2016

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