Provider Demographics
NPI:1053474015
Name:NORTH COUNTRY COMMUNITY MENTAL HEALTH
Entity Type:Organization
Organization Name:NORTH COUNTRY COMMUNITY MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ALEXIS
Authorized Official - Middle Name:
Authorized Official - Last Name:KACZYNSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-347-7890
Mailing Address - Street 1:1420 PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-9420
Mailing Address - Country:US
Mailing Address - Phone:231-439-1233
Mailing Address - Fax:231-347-1241
Practice Address - Street 1:1420 PLAZA DR
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-9420
Practice Address - Country:US
Practice Address - Phone:231-439-1233
Practice Address - Fax:231-347-1241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4476116Medicaid
MI4476072Medicaid
MI4476125Medicaid
MI4476116Medicaid