Basic Information
| Provider Information | |||||||||
| NPI: | 1881622892 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY MENTAL HEALTH FOR CENTRAL MICHIGAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 S CRAPO ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MT PLEASANT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488582941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897736961 | ||||||||
| FaxNumber: | 9897731968 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 S CRAPO ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MT PLEASANT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488582941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897736961 | ||||||||
| FaxNumber: | 9897731968 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 11/30/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 11/23/2018 | ||||||||
| NPIReactivationDate: | 11/30/2018 | ||||||||
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| AuthorizedOfficialLastName: | OBERMESIK | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9897725930 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 6401006136 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 103T00000X | 6301011699 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 1041C0700X | 6801084856 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 363LP0808X | 4704196395 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 225XM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Mental Health | 251S00000X | MI | N | Agencies | Community/Behavioral Health | 2084P0800X | 5101010873 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 214344340 | 05 | MI | MEDICAID | 774352754 | 05 | MI | MEDICAID | 1009798 | 01 | MI | MCLAREN HEALTH PLAN | OTHER | 750910703 | 01 | MI | BLUE CROSS/BLUE SHIELD | OTHER |