Provider Demographics
NPI:1689796930
Name:CHIPPEWA COUNTY HEALTH DEPARTMENT
Entity Type:Organization
Organization Name:CHIPPEWA COUNTY HEALTH DEPARTMENT
Other - Org Name:SAULT HIGH ADOLESCENT CARE CENTER (SHACC)
Other - Org Type:Other Name
Authorized Official - Title/Position:HEALTH OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:SENKUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-253-3103
Mailing Address - Street 1:508 ASHMUN ST STE 120
Mailing Address - Street 2:
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783-1976
Mailing Address - Country:US
Mailing Address - Phone:906-635-1568
Mailing Address - Fax:906-253-1466
Practice Address - Street 1:904 MARQUETTE AVE
Practice Address - Street 2:ROOM 622
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-3301
Practice Address - Country:US
Practice Address - Phone:906-632-5690
Practice Address - Fax:906-635-1325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QD0000X
MI6301008585261QM0855X
MI4301030101261QP2300X, 261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4905013Medicaid
MI4905004Medicaid
MI680A710440OtherBCBS-MENTAL HEALTH
MI4904983Medicaid
MI500A710530OtherBCBS-NP GROUP
MI4904992Medicaid
MI4905004Medicaid