Great Lakes TTC,LLC

Primary specialty

Adult Mental Health Clinic/CenterTaxonomy code 261QM0850X

License

6801089396 Issued in MI

Legal business name

GREAT LAKES TTC,LLC

Practice address

2206 Mitchell Park Dr Ste 10
Petoskey, MI 49770-8674

Phone

(231) 487-2415

NPI assigned

Feb 12, 2013

Last updated

Feb 12, 2013By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Derek Everett Johnson, LMSW

Title

Owner

Phone

(231) 487-2415

Specialties & licenses 1

Addresses

Other identifiers 1

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

{
    "created_epoch": "1360627200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1360627200000",
    "number": "1659610608",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6935 ZENITH HEIGHTS RD",
            "city": "BOYNE CITY",
            "state": "MI",
            "postal_code": "497129356",
            "telephone_number": "231-675-5032"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2206 MITCHELL PARK DR STE 10",
            "city": "PETOSKEY",
            "state": "MI",
            "postal_code": "497708674",
            "telephone_number": "231-487-2415"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GREAT LAKES TTC,LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-02-12",
        "last_updated": "2013-02-12",
        "status": "A",
        "authorized_official_last_name": "JOHNSON",
        "authorized_official_first_name": "DEREK",
        "authorized_official_middle_name": "EVERETT",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "231-487-2415",
        "authorized_official_credential": "LMSW"
    },
    "taxonomies": [
        {
            "code": "261QM0850X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Adult Mental Health",
            "state": "MI",
            "license": "6801089396",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "INDIVIDUAL NPI",
            "identifier": "1700139904",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Great Lakes Cardiothoracic & Vascular Surgery PLLC
• Great Lakes Digestive Health Assc PC
• Great Lakes Ear Nose & Throat Specialists PC
• Great Lakes Neurology, PC
• Great Lakes Oral and Maxillofacial Surgery P.C.
• John K. Grebe, PSY.D.
• Charles R Green, PA-C
• Aaron Charles Greene, P.A.
• Amanda Danielle Greene
• Anthony James Greenough

• Adult Mental Health Clinic/Center in Petoskey, MI
• Providers in Petoskey, MI by specialty
• Adult Mental Health Clinic/Center in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 12, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.