Basic Information
| Provider Information | |||||||||
| NPI: | 1245303890 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MONROE COMMUNITY MENTAL HEALTH AUTHORITY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 S RAISINVILLE RD | ||||||||
| Address2: | PO BOX 0726 | ||||||||
| City: | MONROE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481619754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342437340 | ||||||||
| FaxNumber: | 7342435506 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 S RAISINVILLE RD | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481619754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342437340 | ||||||||
| FaxNumber: | 7342435506 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 09/25/2008 | ||||||||
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| AuthorizedOfficialLastName: | TERWILLIGER | ||||||||
| AuthorizedOfficialFirstName: | JANE | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7342437340 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | MSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 4355907 | 05 | MI | MEDICAID | 4456552 | 05 | MI | MEDICAID |