Provider Demographics
NPI:1235491556
Name:FRESH AIRE SAMARITAN COUNSELING CENTER
Entity Type:Organization
Organization Name:FRESH AIRE SAMARITAN COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:MCILVENNA
Authorized Official - Suffix:
Authorized Official - Credentials:DMIN
Authorized Official - Phone:989-835-7511
Mailing Address - Street 1:315 W LARKIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-5152
Mailing Address - Country:US
Mailing Address - Phone:989-835-7511
Mailing Address - Fax:
Practice Address - Street 1:315 W LARKIN ST
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-5152
Practice Address - Country:US
Practice Address - Phone:989-835-7511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-12
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401010105251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health