Provider Demographics
NPI:1518068071
Name:NORTHERN LAKES COMMUNITY MENTAL HEALTH AUTHORITY
Entity Type:Organization
Organization Name:NORTHERN LAKES COMMUNITY MENTAL HEALTH AUTHORITY
Other - Org Name:
Other - Org Type:
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 STREET
Mailing Address - Street 2:SUITE A
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:231-935-3856
Practice Address - Street 1:105 HALL STREET
Practice Address - Street 2:SUITE A
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:231-935-3856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM007933OtherTRI CARE CHAMPUS
MI0260B81097OtherBCBSM NON OPC PHYSICIANS
MI104985OtherPREFERRED CHOICES
MI21 4540048Medicaid