Basic Information
| Provider Information | |||||||||
| NPI: | 1164943353 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY SUPPORTIVE SERVICES OF NORTHERN MICHIGAN LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 121 N MITCHELL ST | ||||||||
| Address2: | |||||||||
| City: | CADILLAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 496011879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2318788189 | ||||||||
| FaxNumber: | 5173239531 | ||||||||
| Practice Location | |||||||||
| Address1: | 121 N MITCHELL ST | ||||||||
| Address2: | |||||||||
| City: | CADILLAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 496011879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2318788189 | ||||||||
| FaxNumber: | 5173239531 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | DEVERMAN | ||||||||
| AuthorizedOfficialFirstName: | JESSICA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2318788189 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LLMSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801095051 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.