Organization
GREAT LAKES TTC,LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DEREK EVERETT JOHNSON LMSW (OWNER)
(231) 487-2415
Entity
Organization
Contact information
Practice address
2206 MITCHELL PARK DR STE 10, PETOSKEY, MI 49770-8674
(231) 487-2415
Mailing address
6935 ZENITH HEIGHTS RD, BOYNE CITY, MI 49712-9356
(231) 675-5032
Taxonomy
Speciality
Code
Description
License number
State
261QM0850X
Adult Mental Health Clinic/Center
Primary
6801089396
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1700139904
INDIVIDUAL NPI
MI
Enumeration date
02/12/2013
Last updated
02/12/2013
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