Provider Demographics
NPI:1912957143
Name:GOGEBIC COUNTY COMMUNITY MENTAL HEALTH AUTHORITY
Entity Type:Organization
Organization Name:GOGEBIC COUNTY COMMUNITY MENTAL HEALTH AUTHORITY
Other - Org Name:GOGEBIC COUNTY COMMUNITY MENTAL HEALTH
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:MRS
Authorized Official - First Name:TESS
Authorized Official - Middle Name:
Authorized Official - Last Name:GREENOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-229-6100
Mailing Address - Street 1:103 W US HIGHWAY 2
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:49968-9515
Mailing Address - Country:US
Mailing Address - Phone:906-229-6100
Mailing Address - Fax:906-229-6191
Practice Address - Street 1:103 W US HIGHWAY 2
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:MI
Practice Address - Zip Code:49968-9515
Practice Address - Country:US
Practice Address - Phone:906-229-6100
Practice Address - Fax:906-229-6191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI750910818OtherBLUE CROSS OPC
MIIG027143OtherMAGELLAN STATE OF MI GROU
MI1708119Medicaid
MI4351265Medicaid
MI0B76001Medicare PIN
MI750910818OtherBLUE CROSS OPC