Provider Demographics
NPI:1144378381
Name:NORTHEAST MICHIGAN COMMUNITY MENTAL HEALTH AUTHORITY
Entity Type:Organization
Organization Name:NORTHEAST MICHIGAN COMMUNITY MENTAL HEALTH AUTHORITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:A
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-356-2161
Mailing Address - Street 1:400 JOHNSON ST
Mailing Address - Street 2:
Mailing Address - City:ALPENA
Mailing Address - State:MI
Mailing Address - Zip Code:49707-1434
Mailing Address - Country:US
Mailing Address - Phone:989-356-2161
Mailing Address - Fax:989-354-5898
Practice Address - Street 1:400 JOHNSON ST
Practice Address - Street 2:
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707-1434
Practice Address - Country:US
Practice Address - Phone:989-356-2161
Practice Address - Fax:989-354-5898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-06
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4352772Medicaid
MI4458332Medicaid
MI1708100Medicaid
MI26-0-Z4-1060-0OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI26-0-Z4-1060-0OtherBLUE CROSS BLUE SHIELD OF MICHIGAN