Provider Demographics
NPI:1366931453
Name:THIRD COAST CENTER FOR EMOTIONAL WELLNESS PLLC
Entity type:Organization
Organization Name:THIRD COAST CENTER FOR EMOTIONAL WELLNESS PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAKOB
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSSI
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:231-632-0814
Mailing Address - Street 1:1601 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-2923
Mailing Address - Country:US
Mailing Address - Phone:231-632-0814
Mailing Address - Fax:
Practice Address - Street 1:733 E 8TH ST STE 204
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-2665
Practice Address - Country:US
Practice Address - Phone:231-753-3134
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-04
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401015285261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health