Provider Demographics
NPI:1174139968
Name:GREAT LAKES TELETHERAPY
Entity type:Organization
Organization Name:GREAT LAKES TELETHERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:LEAH
Authorized Official - Middle Name:R
Authorized Official - Last Name:BROCK
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:734-224-3773
Mailing Address - Street 1:707 W LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-4348
Mailing Address - Country:US
Mailing Address - Phone:734-224-3773
Mailing Address - Fax:
Practice Address - Street 1:707 W LIBERTY ST
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-4348
Practice Address - Country:US
Practice Address - Phone:734-224-3773
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-17
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health