Basic Information
| Provider Information | |||||||||
| NPI: | 1821316027 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GENESEE COUNTY COMMUNITY MENTAL HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 725 MASON ST | ||||||||
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| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485032421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102573736 | ||||||||
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| Practice Location | |||||||||
| Address1: | 420 W 5TH AVE | ||||||||
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| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485032445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102573736 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2010 | ||||||||
| LastUpdateDate: | 05/12/2010 | ||||||||
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| AuthorizedOfficialLastName: | RUSSELL | ||||||||
| AuthorizedOfficialFirstName: | DANIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICE | ||||||||
| AuthorizedOfficialTelephone: | 8102573707 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TM1800X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Mental Retardation & Developmental Disabilities |
ID Information
| ID | Type | State | Issuer | Description | 774350384 | 05 | MI | MEDICAID |