Basic Information
| Provider Information | |||||||||
| NPI: | 1174701536 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHIAWASSEE COUNTY COMMUNITY MENTAL HEALTH AUTHORITY | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SHIAWASSEE HEALTH & WELLNESS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1555 INDUSTRIAL DR | ||||||||
| Address2: | |||||||||
| City: | OWOSSO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488679775 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897236791 | ||||||||
| FaxNumber: | 9897255061 | ||||||||
| Practice Location | |||||||||
| Address1: | 1555 INDUSTRIAL DR | ||||||||
| Address2: | |||||||||
| City: | OWOSSO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488679775 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897236791 | ||||||||
| FaxNumber: | 9897233191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2008 | ||||||||
| LastUpdateDate: | 12/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STEPHEN | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | FINANCIAL SERVICES SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 9897230732 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SHIAWASSEE COUNTY COMMUNITY MENTAL HEALTH AUTHORITY | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0G86087 | 01 | LMSW-SOCIAL WORKER GROUP | OTHER |