Provider Demographics
NPI:1861610750
Name:MILL STREET PSYCHIATRIC & MEDICAL CLINIC P L C
Entity type:Organization
Organization Name:MILL STREET PSYCHIATRIC & MEDICAL CLINIC P L C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:DELORES
Authorized Official - Last Name:HEASLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-627-7682
Mailing Address - Street 1:927 EVERGREEN RIDGE
Mailing Address - Street 2:
Mailing Address - City:ORTONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48462-8721
Mailing Address - Country:US
Mailing Address - Phone:248-961-3088
Mailing Address - Fax:
Practice Address - Street 1:380 MILL ST
Practice Address - Street 2:
Practice Address - City:ORTONVILLE
Practice Address - State:MI
Practice Address - Zip Code:48462-8721
Practice Address - Country:US
Practice Address - Phone:248-961-3088
Practice Address - Fax:248-627-7682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJH0131192084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0856312505OtherBLUE CROSS MICHIGAN
MI0856312505OtherBLUE CROSS MICHIGAN
MI0856312505OtherBLUE CROSS MICHIGAN