Provider Demographics
NPI:1740447275
Name:CATHOLIC CHARITIES WEST MICHIG
Entity type:Organization
Organization Name:CATHOLIC CHARITIES WEST MICHIG
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR PROGRAM DIRECTOR OF BEHAVIORAL
Authorized Official - Prefix:MS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:MUSTO
Authorized Official - Suffix:
Authorized Official - Credentials:MA LLP
Authorized Official - Phone:616-356-6216
Mailing Address - Street 1:40 JEFFERSON SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503
Mailing Address - Country:US
Mailing Address - Phone:616-356-6216
Mailing Address - Fax:616-732-6390
Practice Address - Street 1:212 1/2 MAPLE STREET
Practice Address - Street 2:
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307
Practice Address - Country:US
Practice Address - Phone:231-796-1583
Practice Address - Fax:231-796-4083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ON62400Medicare UPIN