Basic Information
Provider Information | |||||||||
NPI: | 1104930130 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DOWNRIVER MENTAL HEALTH CLINIC PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ADVANCED COUNSELING SERVICES PC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 20500 EUREKA RD | ||||||||
Address2: | SUITE 200 | ||||||||
City: | TAYLOR | ||||||||
State: | MI | ||||||||
PostalCode: | 481806394 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7342858282 | ||||||||
FaxNumber: | 7342810402 | ||||||||
Practice Location | |||||||||
Address1: | 20500 EUREKA RD | ||||||||
Address2: | SUITE 200 | ||||||||
City: | TAYLOR | ||||||||
State: | MI | ||||||||
PostalCode: | 481806394 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7342858282 | ||||||||
FaxNumber: | 7342810402 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/18/2006 | ||||||||
LastUpdateDate: | 09/02/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BEACH | ||||||||
AuthorizedOfficialFirstName: | PATRICIA | ||||||||
AuthorizedOfficialMiddleName: | F | ||||||||
AuthorizedOfficialTitleorPosition: | PROVIDER RELATIONS DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 2482130501 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LMSW ACSW BCD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
ID | Type | State | Issuer | Description | 4449395 | 01 | MI | AETNA | OTHER | 003433000 188713000 | 01 | MI | MAGELLAN | OTHER | BM820042 | 01 | MI | MCARE | OTHER | 511213 | 01 |   | CARE CHOICES | OTHER | 004241F3 | 01 | MI | HAP | OTHER | 101039 | 01 | MI | VALUE OPTIONS | OTHER | 4441363 | 01 | MI | TEAMSTERS | OTHER | 7509106200 | 01 |   | BCBS OF MI:MENTAL HEALTH | OTHER |