Provider Demographics
NPI:1821316027
Name:GENESEE COUNTY COMMUNITY MENTAL HEALTH
Entity Type:Organization
Organization Name:GENESEE COUNTY COMMUNITY MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICE
Authorized Official - Prefix:
Authorized Official - First Name:DANIS
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-257-3707
Mailing Address - Street 1:725 MASON ST
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48503-2421
Mailing Address - Country:US
Mailing Address - Phone:810-257-3736
Mailing Address - Fax:
Practice Address - Street 1:420 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-2445
Practice Address - Country:US
Practice Address - Phone:810-257-3736
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-12
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI774350384Medicaid