Basic Information
| Provider Information | |||||||||
| NPI: | 1346378981 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DOWNRIVER MENTAL HEALTH CLINIC PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ADVANCED COUNSELING SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20600 EUREKA RD | ||||||||
| Address2: | SUITE 819 | ||||||||
| City: | TAYLOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481805343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342852828 | ||||||||
| FaxNumber: | 7342810402 | ||||||||
| Practice Location | |||||||||
| Address1: | 29201 TELEGRAPH RD | ||||||||
| Address2: | SUITE 550 | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480341331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2482130501 | ||||||||
| FaxNumber: | 2482130521 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2007 | ||||||||
| LastUpdateDate: | 07/19/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BEACH | ||||||||
| AuthorizedOfficialFirstName: | PATRICIA | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER RELATIONS | ||||||||
| AuthorizedOfficialTelephone: | 2482130501 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LMSW ACSW BCD | ||||||||
| NPICertificationDate: | |||||||||
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 | 511213 | 01 | MI | CARE CHOICES | OTHER | BM820042 | 01 | MI | MCARE | OTHER | 101039 | 01 | MI | VALUE OPTIONS | OTHER | 90197000 | 01 | MI | MAGELLAN STATE OF MI | OTHER | 4449395 | 01 | MI | AETNA | OTHER | 7509108970 | 01 | MI | BCBS | OTHER | 004241F3 | 01 | MI | HAP | OTHER | 4441728 | 01 | MI | TEAMSTERS | OTHER |