Provider Demographics
NPI:1710066253
Name:KALAMAZOO COUNTY COMMUNITY MENTAL HEALTH AUTHORITY
Entity Type:Organization
Organization Name:KALAMAZOO COUNTY COMMUNITY MENTAL HEALTH AUTHORITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPUTY DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAT
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-553-8017
Mailing Address - Street 1:2030 PORTAGE ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49001-3836
Mailing Address - Country:US
Mailing Address - Phone:269-553-7000
Mailing Address - Fax:269-553-8012
Practice Address - Street 1:615 E CROSSTOWN PKWY
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49001-2501
Practice Address - Country:US
Practice Address - Phone:269-553-7000
Practice Address - Fax:269-553-8012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
MISA0390177261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4352736Medicaid
MI0N19710Medicare PIN