Provider Demographics
NPI:1821133265
Name:ST CLAIR COUNTY COMMUNITY MENTAL HEALTH AUTHORITY
Entity Type:Organization
Organization Name:ST CLAIR COUNTY COMMUNITY MENTAL HEALTH AUTHORITY
Other - Org Name:ST CLAIR COUNTY COMMUNITY MENTAL HEALTH SOUTH-MARINE CITY
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 1:6221 KING RD
Mailing Address - Street 2:
Mailing Address - City:MARINE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48039-1428
Mailing Address - Country:US
Mailing Address - Phone:810-765-5010
Mailing Address - Fax:
Practice Address - Street 1:6221 KING RD
Practice Address - Street 2:
Practice Address - City:MARINE CITY
Practice Address - State:MI
Practice Address - Zip Code:48039-1428
Practice Address - Country:US
Practice Address - Phone:810-765-5010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST CLAIR COUNTY COMMUNITY MENTAL HEALTH AUTHORITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-21
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1708164Medicaid
MI4349015Medicaid
MI0N96150Medicare PIN
MI0M97230Medicare PIN
MI0M97240Medicare PIN
MI4349015Medicaid