Provider Demographics
NPI:1831328210
Name:PORT HURON BEHAVIORAL SPECIALISTS
Entity type:Organization
Organization Name:PORT HURON BEHAVIORAL SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIPA
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:ZYLANOFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-633-9211
Mailing Address - Street 1:309 MCMORRAN BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3807
Mailing Address - Country:US
Mailing Address - Phone:810-488-7974
Mailing Address - Fax:810-794-8851
Practice Address - Street 1:309 MCMORRAN BLVD
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3807
Practice Address - Country:US
Practice Address - Phone:810-488-7974
Practice Address - Fax:810-794-7751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-07
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301055492084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty