MEDICARE: PINE RIVER PSYCHOLOGICAL SERVICES PLLC

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	103T00000X	Psychologist

General Provider Information

NPI Number	:	1992660005
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PINE RIVER PSYCHOLOGICAL SERVICES PLLC

Provider Business Mailing Address
First Line	:	4053 OLD 31 S
Second Line	:
City	:	CHARLEVOIX
State	:	MI
Zip	:	49720-9691
Country	:	US
Telephone Number	:	650-387-3927
Fax Number	:

Provider Business Practice Location Address
First Line	:	223 BRIDGE ST
Second Line	:
City	:	CHARLEVOIX
State	:	MI
Zip	:	49720-1400
Country	:	US
Telephone Number	:	650-387-3927
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	DR. MICHAEL DI MARTINO
Credential	:	PSY.D.
Telephone Number	:	650-387-3927

Provider Enumeration Date	:	12/20/2025
Last Update Date	:	12/20/2025

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