Basic Information
| Provider Information | |||||||||
| NPI: | 1497749279 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHIAWASSEE COUNTY COMMUNITY MENTAL HEALTH AUTHORITY | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SHIAWASSEE HEALTH & WELLNESS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 9897255061 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2005 | ||||||||
| LastUpdateDate: | 01/18/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STEPHEN | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | FINANCIAL SERVICES SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 9897230732 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | MI | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | P10G81020 | 01 | MI | BCBS | OTHER | 0G86005 | 01 | MI | BCBS | OTHER | 105813 | 01 | VALUE OPTIONS | OTHER | 0G86087 | 01 | MI | BCBS | OTHER | 774351238 | 05 | MI | MEDICAID |