Basic Information
| Provider Information | |||||||||
| NPI: | 1295866135 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DOWNRIVER MENTAL HEALTH CLINIC PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LIFESTANCE HEALTH, INC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20500 EUREKA RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | TAYLOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481806394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342858282 | ||||||||
| FaxNumber: | 7342810402 | ||||||||
| Practice Location | |||||||||
| Address1: | 20500 EUREKA RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | TAYLOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481806394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342858282 | ||||||||
| FaxNumber: | 7342810402 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2007 | ||||||||
| LastUpdateDate: | 08/11/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CONRAD | ||||||||
| AuthorizedOfficialFirstName: | KRISTINA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 5178823732 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/11/2022 | ||||||||
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 | 7509203930 | 01 | MI | BCBS SA | OTHER |