Provider Demographics
NPI:1073987616
Name:CENTRAL MICHIGAN UNIVERSITY
Entity Type:Organization
Organization Name:CENTRAL MICHIGAN UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:SHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:SIAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-774-2597
Mailing Address - Street 1:1101 HEALTH PROFESSIONS BLDG
Mailing Address - Street 2:STE 2105
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48859-0001
Mailing Address - Country:US
Mailing Address - Phone:989-774-3904
Mailing Address - Fax:989-774-1891
Practice Address - Street 1:1101 HEALTH PROFESSIONS BLDG
Practice Address - Street 2:STE 2105
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48859-0001
Practice Address - Country:US
Practice Address - Phone:989-774-3904
Practice Address - Fax:989-774-1891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-19
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
193400000XOtherTAXONOMY