Provider Demographics
NPI:1205023652
Name:COPPER COUNTRY COMMUNITY MENTAL HEALTH SERVICES
Entity Type:Organization
Organization Name:COPPER COUNTRY COMMUNITY MENTAL HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:J
Authorized Official - Last Name:POLLACK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:906-482-9400
Mailing Address - Street 1:901 W. MEMORIAL DR.
Mailing Address - Street 2:
Mailing Address - City:HOUGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:49931
Mailing Address - Country:US
Mailing Address - Phone:906-482-9400
Mailing Address - Fax:906-483-0269
Practice Address - Street 1:15644 SKANEE RD
Practice Address - Street 2:
Practice Address - City:LANSE
Practice Address - State:MI
Practice Address - Zip Code:49946-9003
Practice Address - Country:US
Practice Address - Phone:906-524-5885
Practice Address - Fax:906-483-0269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-01
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1707962Medicaid
10603OtherBLUE CROSS BLUE SHIELD MI
MI1707962Medicaid