Basic Information
| Provider Information | |||||||||
| NPI: | 1255629358 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MICHIGAN STATE UNIVERSITY CLINICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 804 SERVICE RD STE A114 | ||||||||
| Address2: | |||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488247038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173557648 | ||||||||
| FaxNumber: | 5174321319 | ||||||||
| Practice Location | |||||||||
| Address1: | 804 SERVICE RD STE A114 | ||||||||
| Address2: | |||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488247038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173557648 | ||||||||
| FaxNumber: | 5174321319 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2011 | ||||||||
| LastUpdateDate: | 04/13/2012 | ||||||||
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| AuthorizedOfficialLastName: | ZALDOKAS | ||||||||
| AuthorizedOfficialFirstName: | CYNTHIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | MGR PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 5173553503 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 6301006498 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 103G00000X | 6301014684 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
No ID Information.