Healthcare Provider Details

I. General information

NPI: 1033280763
Provider Name (Legal Business Name): BERRIEN MENTAL HEALTH AUTHORITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 01/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1485 S. M-139
BENTON HARBOR MI
49022
US

IV. Provider business mailing address

1485 S. M-139
BENTON HARBOR MI
49022
US

V. Phone/Fax

Practice location:
  • Phone: 269-925-0585
  • Fax: 269-927-1326
Mailing address:
  • Phone: 269-925-0585
  • Fax: 269-927-1326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: ALLEN R EDLEFSON
Title or Position: CEO
Credential:
Phone: 269-925-0585