Provider Demographics
NPI:1780159004
Name:GREAT LAKES CLINIC AND CONSULTANTS
Entity type:Organization
Organization Name:GREAT LAKES CLINIC AND CONSULTANTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:DICH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:920-415-0505
Mailing Address - Street 1:1407 NORTH 8TH STREET
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081
Mailing Address - Country:US
Mailing Address - Phone:920-415-0505
Mailing Address - Fax:
Practice Address - Street 1:1407 NORTH 8TH STREET
Practice Address - Street 2:SUITE 203
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081
Practice Address - Country:US
Practice Address - Phone:920-415-0505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-13
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)