Provider Demographics
NPI:1649581794
Name:MICHIGAN PSYCHIATRIC & BEHAVIORAL ASSOC
Entity Type:Organization
Organization Name:MICHIGAN PSYCHIATRIC & BEHAVIORAL ASSOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:BA, LBSW
Authorized Official - Phone:989-922-4900
Mailing Address - Street 1:690 S TRUMBULL ST
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48708-7692
Mailing Address - Country:US
Mailing Address - Phone:989-922-4900
Mailing Address - Fax:989-922-4911
Practice Address - Street 1:690 S TRUMBULL ST
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48708-7692
Practice Address - Country:US
Practice Address - Phone:989-922-4900
Practice Address - Fax:989-922-4911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MION34080251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI055552OtherLICENSE
MI4318073Medicaid
MI4704114058OtherNURSE PRACTITIONER
MI561005082OtherPHYSICIAN'S ASSISTANT
MI1080046OtherNCCPA
MI4318091Medicaid
MIML073076OtherLICENSE
MION34080OtherGROUP MEDICARE
MI4318064Medicaid
MIKK058857OtherLICENSE
MIML073076OtherLICENSE
MION34080OtherGROUP MEDICARE
MI4318064Medicaid
MIKK058857OtherLICENSE
MIMC2115461OtherDEA REGISTRATION
MIN34080003Medicare Oscar/Certification
MIBL5931123OtherDEA
MI4704114058OtherNURSE PRACTITIONER
MIG00158Medicare UPIN
MIF70576Medicare UPIN
MIN34080001Medicare Oscar/Certification
MIML1675288OtherDEA REGISTRATION
G76714Medicare UPIN