Basic Information
| Provider Information | |||||||||
| NPI: | 1033437397 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIVINGSTON COUNTY COMMUNITY MENTAL HEALTH AUTHORITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CMH OF LIVINGSTON COUNTY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2280 E GRAND RIVER AVE | ||||||||
| Address2: | |||||||||
| City: | HOWELL | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488438503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5175464126 | ||||||||
| FaxNumber: | 5175461300 | ||||||||
| Practice Location | |||||||||
| Address1: | 2280 E GRAND RIVER AVE | ||||||||
| Address2: | |||||||||
| City: | HOWELL | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488438503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5175464126 | ||||||||
| FaxNumber: | 5175461300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2010 | ||||||||
| LastUpdateDate: | 05/12/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | ANGUS | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5175464126 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | IV | ||||||||
| AuthorizedOfficialCredential: | L.M.S.W. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 0D76011 | 01 | MI | MEDICARE PTAN | OTHER | 0N63530 | 01 | MI | MEDICARE PTAN | OTHER | 0N61370 | 01 | MI | MEDICARE PTAN | OTHER |