Provider Demographics
NPI:1164641676
Name:NORTHERN MICHIGAN SUBSTANCE ABUSE SERVICES, INC.
Entity Type:Organization
Organization Name:NORTHERN MICHIGAN SUBSTANCE ABUSE SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SUE
Authorized Official - Middle Name:
Authorized Official - Last Name:WINTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-732-1791
Mailing Address - Street 1:2136 W M 32
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-9282
Mailing Address - Country:US
Mailing Address - Phone:989-732-1791
Mailing Address - Fax:989-732-7052
Practice Address - Street 1:2136 W M 32
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-9282
Practice Address - Country:US
Practice Address - Phone:989-732-1791
Practice Address - Fax:989-732-7052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISA0690031251S00000X
MI690031261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI174458207Medicaid