Provider Demographics
NPI:1417481136
Name:NORTHERN LAKES COMMUNITY MENTAL HEALTH AUTHORITY
Entity Type:Organization
Organization Name:NORTHERN LAKES COMMUNITY MENTAL HEALTH AUTHORITY
Other - Org Name:NORTHERN LAKES INTEGRATED HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:STEVENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-922-4850
Mailing Address - Street 1:105 HALL ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2288
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 HALL ST
Practice Address - Street 2:SUITE C
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2288
Practice Address - Country:US
Practice Address - Phone:231-935-3062
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHERN LAKES COMMUNITY MENTAL HEALTH AUTHORITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-04-19
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center