Basic Information
| Provider Information | |||||||||
| NPI: | 1710074448 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MONTCALM CARE NETWORK | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | THE MONTCALM CENTER FOR BEHAVIORAL HEALTH | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 611 N STATE STREET | ||||||||
| Address2: | |||||||||
| City: | STANTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48888 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898317520 | ||||||||
| FaxNumber: | 9898317578 | ||||||||
| Practice Location | |||||||||
| Address1: | 611 N STATE STREET | ||||||||
| Address2: | |||||||||
| City: | STANTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48888 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898317520 | ||||||||
| FaxNumber: | 9898317578 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 04/18/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WISE | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSOCIATE DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 9898317577 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 1712461 | 05 | MI | MEDICAID |