Provider Demographics
NPI:1699814905
Name:MANISTEE BENZIE COMMUNITY MENTAL HEALTH
Entity Type:Organization
Organization Name:MANISTEE BENZIE COMMUNITY MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:NIEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-398-2013
Mailing Address - Street 1:310 GLOCHESKI DR
Mailing Address - Street 2:
Mailing Address - City:MANISTEE
Mailing Address - State:MI
Mailing Address - Zip Code:49660-2639
Mailing Address - Country:US
Mailing Address - Phone:877-398-2013
Mailing Address - Fax:231-723-1504
Practice Address - Street 1:310 GLOCHESKI DR
Practice Address - Street 2:
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660-2639
Practice Address - Country:US
Practice Address - Phone:877-398-2013
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1705304Medicaid
MI=========OtherTAX ID NUMBER
MI1705304Medicaid