Basic Information
Provider Information | |||||||||
NPI: | 1851865638 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HARBOR HALL, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 704 EMMET ST | ||||||||
Address2: |   | ||||||||
City: | PETOSKEY | ||||||||
State: | MI | ||||||||
PostalCode: | 497702910 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2236 E MITCHELL RD | ||||||||
Address2: |   | ||||||||
City: | PETOSKEY | ||||||||
State: | MI | ||||||||
PostalCode: | 497709604 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2313479880 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/15/2019 | ||||||||
LastUpdateDate: | 01/21/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PENNINGTON | ||||||||
AuthorizedOfficialFirstName: | KAYLA | ||||||||
AuthorizedOfficialMiddleName: | JANE | ||||||||
AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
AuthorizedOfficialTelephone: | 2313475511 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/21/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
ID | Type | State | Issuer | Description | SA0240037 | 05 | MI |   | MEDICAID |