Basic Information
| Provider Information | |||||||||
| NPI: | 1760818827 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BERRIEN MENTAL HEALTH AUTHORITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | RIVERWOOD CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1485 M 139 | ||||||||
| Address2: | |||||||||
| City: | BENTON HARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490225711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699341611 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1485 M 139 | ||||||||
| Address2: | |||||||||
| City: | BENTON HARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490225711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699341611 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2013 | ||||||||
| LastUpdateDate: | 10/05/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LYZENGA | ||||||||
| AuthorizedOfficialFirstName: | BRETT | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2699341611 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 1716175 | 05 | MI | MEDICAID |