Provider Demographics
NPI:1245651405
Name:WMT INC. RECOVERY & HOUSING CENTER
Entity type:Organization
Organization Name:WMT INC. RECOVERY & HOUSING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:CHURCHWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-728-2138
Mailing Address - Street 1:2333 JARMAN ST
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-1655
Mailing Address - Country:US
Mailing Address - Phone:231-739-6840
Mailing Address - Fax:231-722-4771
Practice Address - Street 1:1823 COMMERCE ST
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49441-2608
Practice Address - Country:US
Practice Address - Phone:231-728-2138
Practice Address - Fax:231-722-4771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-13
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISA0610022101YP2500X, 103TC0700X, 103TC1900X, 103TC2200X, 324500000X, 251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251B00000XAgenciesCase Management
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MISA2312200013009Medicaid