Provider Demographics
NPI:1417011701
Name:AUSABLE VALLEY COMMUNITY MENTAL HEALTH SERVICES BOARD
Entity Type:Organization
Organization Name:AUSABLE VALLEY COMMUNITY MENTAL HEALTH SERVICES BOARD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:FLOYD
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:989-362-8636
Mailing Address - Street 1:1199 W HARRIS AVE
Mailing Address - Street 2:PO BOX 310
Mailing Address - City:TAWAS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48764-9310
Mailing Address - Country:US
Mailing Address - Phone:989-362-8636
Mailing Address - Fax:
Practice Address - Street 1:1199 W HARRIS AVE
Practice Address - Street 2:
Practice Address - City:TAWAS CITY
Practice Address - State:MI
Practice Address - Zip Code:48764-9310
Practice Address - Country:US
Practice Address - Phone:989-362-8636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4456570Medicaid
MI1706830Medicaid
MI4811060Medicaid
MI1706830Medicaid
MI4811060Medicaid