Provider Demographics
NPI:1033280763
Name:BERRIEN MENTAL HEALTH AUTHORITY
Entity Type:Organization
Organization Name:BERRIEN MENTAL HEALTH AUTHORITY
Other - Org Name:RIVERWOOD CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:EDLEFSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-925-0585
Mailing Address - Street 1:1485 S. M-139
Mailing Address - Street 2:
Mailing Address - City:BENTON HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:49022
Mailing Address - Country:US
Mailing Address - Phone:269-925-0585
Mailing Address - Fax:269-927-1326
Practice Address - Street 1:1485 S. M-139
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022
Practice Address - Country:US
Practice Address - Phone:269-925-0585
Practice Address - Fax:269-927-1326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI21-1716175Medicaid
MI750910730OtherBCBS
MI0N26020Medicare PIN
MI0N30810Medicare PIN