Basic Information
| Provider Information | |||||||||
| NPI: | 1134264435 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MACOMB COUNTY COMMUNITY MENTAL HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 46360 GRATIOT AVE | ||||||||
| Address2: | |||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480512800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5869480213 | ||||||||
| FaxNumber: | 5869480213 | ||||||||
| Practice Location | |||||||||
| Address1: | 46360 GRATIOT AVE | ||||||||
| Address2: | |||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480512800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5869480224 | ||||||||
| FaxNumber: | 5869480213 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | COONAN-COX | ||||||||
| AuthorizedOfficialFirstName: | CAROLE | ||||||||
| AuthorizedOfficialMiddleName: | F. | ||||||||
| AuthorizedOfficialTitleorPosition: | CARE COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 5869480224 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | R.N.,M.A.,L.P.C. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 6401005800 | MI | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 6401005800 | 01 | MI | L.P.C. | OTHER | 4704063386 | 01 | MI | REGISTERED NURSE | OTHER |