Basic Information
| Provider Information | |||||||||
| NPI: | 1861430381 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BRANCH COUNTY COMMUNITY MENTAL HEALTH AUTHORITY | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PINES BEHAVIORAL HEALTH SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 200 VISTA DR | ||||||||
| Address2: | |||||||||
| City: | COLDWATER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490361776 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172782129 | ||||||||
| FaxNumber: | 5172798172 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 VISTA DR | ||||||||
| Address2: | |||||||||
| City: | COLDWATER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172782129 | ||||||||
| FaxNumber: | 5172798172 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 05/22/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILBER | ||||||||
| AuthorizedOfficialFirstName: | ROBBIN | ||||||||
| AuthorizedOfficialMiddleName: | SUE | ||||||||
| AuthorizedOfficialTitleorPosition: | FINANCE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5172782129 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BRANCH COUNTY COMMUNITY MENTAL HEALTH AUTHORITY | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | BBA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 75-09-10497 | 01 | MI | BCBS | OTHER | 774352834 | 05 | MI | MEDICAID |