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	101Y00000X	Counselor
2	101YA0400X	Addiction (Substance Use Disorder) Counselor
3	101YM0800X	Mental Health Counselor
4	103T00000X	Psychologist
5	103TC0700X	Clinical Psychologist
6	104100000X	Social Worker
7	1041C0700X	Clinical Social Worker
8	2084P0800X	Psychiatry Physician
9	101YP2500X	Professional Counselor
10	2084A0401X	Addiction Medicine (Psychiatry & Neurology) Physician
11	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	SA0790015	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	750910576	OTHER	MI	BCBS OF MICHIGAN
2	034530	OTHER	MI	VALUE OPTIONS
3	20556	OTHER	MI	BCBS SUBSTANCE ABUSE
4	1006309	OTHER	MI	MCLAREN HEALTH ADVANTAGE
5	0D41044	OTHER	MI	BCBS PSYCHIATRIST

General Provider Information

NPI Number	:	1881644789
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	:	989-672-6272

Provider Business Practice Location Address
First Line	:	651 N STATE ST
Second Line	:
City	:	CARO
State	:	MI
Zip	:	48723-1543
Country	:	US
Telephone Number	:	989-673-5700
Fax Number	:	989-672-2555

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

Provider Enumeration Date	:	05/11/2006
Last Update Date	:	12/27/2016

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