Provider Demographics
NPI:1609135409
Name:RASPBERRY MANOR
Entity Type:Organization
Organization Name:RASPBERRY MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CURTIS
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:COUSINEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-636-3900
Mailing Address - Street 1:6141 S STATE RD
Mailing Address - Street 2:
Mailing Address - City:GOODRICH
Mailing Address - State:MI
Mailing Address - Zip Code:48438-8849
Mailing Address - Country:US
Mailing Address - Phone:810-636-3900
Mailing Address - Fax:810-636-3900
Practice Address - Street 1:6141 S STATE RD
Practice Address - Street 2:
Practice Address - City:GOODRICH
Practice Address - State:MI
Practice Address - Zip Code:48438-8849
Practice Address - Country:US
Practice Address - Phone:810-636-3900
Practice Address - Fax:810-636-3900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-14
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF250071517261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health