Basic Information
| Provider Information | |||||||||
| NPI: | 1669795522 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IONIA COUNTY COMMUNITY MENTAL HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 375 APPLE TREE DR | ||||||||
| Address2: | |||||||||
| City: | IONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488467506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6165271790 | ||||||||
| FaxNumber: | 6165271330 | ||||||||
| Practice Location | |||||||||
| Address1: | 375 APPLE TREE DR | ||||||||
| Address2: | |||||||||
| City: | IONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488467506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6165271790 | ||||||||
| FaxNumber: | 6165271330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2010 | ||||||||
| LastUpdateDate: | 03/08/2010 | ||||||||
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| AuthorizedOfficialLastName: | STRUBLE | ||||||||
| AuthorizedOfficialFirstName: | PATRICIA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | REIMBURSEMENT SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 6167751018 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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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 | 774350393 | 05 | MI | MEDICAID |