NPIMap

Organization Active NPI

Old Town Psychological Services

  • Clinical Psychologist
  • Traverse City, MI
National Provider Identifier
1093989162
Registry record updated May 6, 2010
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical PsychologistTaxonomy code 103TC0700X
License
6301008748 Issued in MI
Legal business name
OLD TOWN PSYCHOLOGICAL SERVICES
Practice address
512 S Union St
Traverse City, MI 49684-3247
Phone
(231) 941-6550
NPI assigned
Apr 18, 2008
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 6, 2010

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Michael P Hayes, PH.D.NPI 1528106606
Title
Clinical Director
Phone
(231) 941-6550

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical PsychologistGroup: 193200000X MULTI-SPECIALTY GROUP 103TC0700X 6301008748 MI Primary

Addresses

Primary practice location

512 S Union St
Traverse City, MI 49684-3247

Mailing address

512 S Union St
Traverse City, MI 49684-3247

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20120921000057 MI Part B Supplier - Clinic/Group Practice 2466600101 Receives reassigned benefits from 11 practitioners
Practice locations: Gaylord, MI; Traverse City, MI

National Provider Directory

National Provider Directory
Tax ID family
Old Town Psychological2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Locations

128 N Court Ave
Gaylord, MI 49735
Phone (989) 448-2328

512 S Union St
Traverse City, MI 49684
Phone (231) 941-6550

Ownership & related parties

Subparts reporting this organization as parent 1

Organizations that report themselves as subparts in NPPES and name this organization, in the same state, as their parent.

Practitioners & affiliated clinicians

Practitioners 29

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 29

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1208476800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1273104000000",
    "number": "1093989162",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "512 S UNION ST",
            "city": "TRAVERSE CITY",
            "state": "MI",
            "postal_code": "496843247"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "512 S UNION ST",
            "city": "TRAVERSE CITY",
            "state": "MI",
            "postal_code": "496843247",
            "telephone_number": "231-941-6550"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "OLD TOWN PSYCHOLOGICAL SERVICES",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-04-18",
        "last_updated": "2010-05-06",
        "status": "A",
        "authorized_official_last_name": "HAYES",
        "authorized_official_first_name": "MICHAEL",
        "authorized_official_middle_name": "P",
        "authorized_official_title_or_position": "CLINICAL DIRECTOR",
        "authorized_official_telephone_number": "231-941-6550",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "PH.D."
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist, Clinical",
            "state": "MI",
            "license": "6301008748",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Traverse City, MI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 6, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.