Provider Demographics
NPI:1508967068
Name:NORTHERN LAKES COMMUNITY MENTAL HEALTH AUTHORITY
Entity Type:Organization
Organization Name:NORTHERN LAKES COMMUNITY MENTAL HEALTH AUTHORITY
Other - Org Name:NORTHERN HEALTH CARE MANAGEMENT
Other - Org Type:Other Name
Authorized Official - Title/Position:INTERIM CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-922-4850
Mailing Address - Street 1:105 HALL STREET
Mailing Address - Street 2:SUITE D
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684
Mailing Address - Country:US
Mailing Address - Phone:231-922-4850
Mailing Address - Fax:231-935-4164
Practice Address - Street 1:105 HALL STREET
Practice Address - Street 2:SUITE D
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684
Practice Address - Country:US
Practice Address - Phone:231-922-4850
Practice Address - Fax:231-935-4164
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHERN LAKES COMMUNITY MENTAL HEALTH AUTHORITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-26
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI77 4508846Medicaid