Basic Information
| Provider Information | |||||||||
| NPI: | 1255385399 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MACOMB COUNTY COMMUNITY MENTAL HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22550 HALL RD | ||||||||
| Address2: | |||||||||
| City: | CLINTON TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480361189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864695275 | ||||||||
| FaxNumber: | 5864697958 | ||||||||
| Practice Location | |||||||||
| Address1: | 43740 N GROESBECK HWY | ||||||||
| Address2: | |||||||||
| City: | CLINTON TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480361139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864695774 | ||||||||
| FaxNumber: | 5864697958 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 02/02/2010 | ||||||||
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| AuthorizedOfficialLastName: | JOSEF | ||||||||
| AuthorizedOfficialFirstName: | NORMA | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5869480240 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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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 | 4350464 | 05 | MI | MEDICAID | 3396315 | 01 | MI | TYPE 21 MEDICAID | OTHER |