Provider Demographics
NPI:1508801465
Name:BERRIEN MENTAL HEALTH AUTHORITY
Entity Type:Organization
Organization Name:BERRIEN MENTAL HEALTH AUTHORITY
Other - Org Name:NORTHSTAR CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:EDLEFSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-934-1611
Mailing Address - Street 1:2500 NILES RD STE 7
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-3268
Mailing Address - Country:US
Mailing Address - Phone:269-982-7844
Mailing Address - Fax:269-982-1783
Practice Address - Street 1:2500 NILES RD STE 7
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-3268
Practice Address - Country:US
Practice Address - Phone:269-982-7844
Practice Address - Fax:269-982-1783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI750910476OtherBCBS PIN #
MI0N38010Medicare PIN
MI0N26020Medicare PIN