Basic Information
| Provider Information | |||||||||
| NPI: | 1154612745 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. JOHN PROVIDENCE HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ST. JOHN MACOMB HOSPITAL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11800 EAST TWELVE MILE ROAD | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5865735872 | ||||||||
| FaxNumber: | 5865735583 | ||||||||
| Practice Location | |||||||||
| Address1: | 11800 E 12 MILE RD | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480933472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5865735872 | ||||||||
| FaxNumber: | 5865735583 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2011 | ||||||||
| LastUpdateDate: | 04/29/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | POPE | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINA | ||||||||
| AuthorizedOfficialMiddleName: | MARIA | ||||||||
| AuthorizedOfficialTitleorPosition: | BEHAVIORAL HEALTH INTAKE CLINICIAN | ||||||||
| AuthorizedOfficialTelephone: | 5865735872 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST. JOHN PROVIDENCE HEALTH SYSTEM | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MA LPC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 6401007085 | MI | Y | Hospitals | General Acute Care Hospital |
No ID Information.