Provider Demographics
NPI:1851703417
Name:GRAND TRAVERSE AREA COMMUNITY LIVING MANAGEMENT CORPORATION
Entity Type:Organization
Organization Name:GRAND TRAVERSE AREA COMMUNITY LIVING MANAGEMENT CORPORATION
Other - Org Name:BRICKWAYS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:ONAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-932-9030
Mailing Address - Street 1:935 BARLOW ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-4250
Mailing Address - Country:US
Mailing Address - Phone:231-932-9030
Mailing Address - Fax:231-941-3421
Practice Address - Street 1:935 BARLOW ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-4250
Practice Address - Country:US
Practice Address - Phone:231-932-9030
Practice Address - Fax:231-941-3421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-29
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401007670251B00000X, 253Z00000X
251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No251B00000XAgenciesCase Management
No253Z00000XAgenciesIn Home Supportive Care