Provider Demographics
NPI:1689783672
Name:ST CLAIR COUNTY COMMUNITY MENTAL HEALTH AUTHORITY
Entity Type:Organization
Organization Name:ST CLAIR COUNTY COMMUNITY MENTAL HEALTH AUTHORITY
Other - Org Name:CHILDREN'S WAIVER SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:B
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-985-8900
Mailing Address - Street 1:3111 ELECTRIC AVENUE
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-8127
Mailing Address - Country:US
Mailing Address - Phone:810-985-8900
Mailing Address - Fax:810-985-7620
Practice Address - Street 1:3111 ELECTRIC AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-8127
Practice Address - Country:US
Practice Address - Phone:810-985-8900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4349015Medicaid
MI1708164Medicaid
MI1708164Medicaid
MI0N96320Medicare PIN
MI0M97240Medicare PIN
MI0M97230Medicare PIN