MEDICARE: BERRIEN MENTAL HEALTH AUTHORITY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	101YM0800X	Mental Health Counselor
2	103TC0700X	Clinical Psychologist
3	2084P0800X	Psychiatry Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	750910476	OTHER	MI	BCBS PIN #

General Provider Information

NPI Number	:	1508801465
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BERRIEN MENTAL HEALTH AUTHORITY

Provider Business Mailing Address
First Line	:	2500 NILES RD STE 7
Second Line	:
City	:	SAINT JOSEPH
State	:	MI
Zip	:	49085-3268
Country	:	US
Telephone Number	:	269-982-7844
Fax Number	:	269-982-1783

Provider Business Practice Location Address
First Line	:	2500 NILES RD STE 7
Second Line	:
City	:	SAINT JOSEPH
State	:	MI
Zip	:	49085-3268
Country	:	US
Telephone Number	:	269-982-7844
Fax Number	:	269-982-1783

Authorized Official
Title or Position	:	CEO
Name	:	MR. ALLEN R EDLEFSON
Credential	:
Telephone Number	:	269-934-1611

Provider Enumeration Date	:	06/17/2006
Last Update Date	:	09/07/2010

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Directions to “BERRIEN MENTAL HEALTH AUTHORITY ” Practice Location

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