Provider Demographics
NPI:1629161567
Name:HIAWATHA COMMUNITY BEHAVIORAL HEALTH AUTHORITY
Entity Type:Organization
Organization Name:HIAWATHA COMMUNITY BEHAVIORAL HEALTH AUTHORITY
Other - Org Name:HIAWATHA BEHAVIORAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HARMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-341-2144
Mailing Address - Street 1:125 N LAKE ST
Mailing Address - Street 2:
Mailing Address - City:MANISTIQUE
Mailing Address - State:MI
Mailing Address - Zip Code:49854-1234
Mailing Address - Country:US
Mailing Address - Phone:906-341-2144
Mailing Address - Fax:906-341-5793
Practice Address - Street 1:3865 S MACKINAC TRL
Practice Address - Street 2:
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-9286
Practice Address - Country:US
Practice Address - Phone:906-632-2805
Practice Address - Fax:906-632-1163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7509104110OtherBCBS
MI774361332Medicaid
MI7509104110OtherBCBS
MI0M49630Medicare ID - Type UnspecifiedGROUP NUMBER/SOCIAL WORK