Healthcare Provider Details

I. General information

NPI: 1134470495
Provider Name (Legal Business Name): MACOMB COUNTY COMMUNITY MENTAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2012
Last Update Date: 09/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43740 N GROESBECK HWY
CLINTON TOWNSHIP MI
48036-1139
US

IV. Provider business mailing address

43740 N GROESBECK HWY
CLINTON TOWNSHIP MI
48036-1139
US

V. Phone/Fax

Practice location:
  • Phone: 586-469-7629
  • Fax: 586-469-7662
Mailing address:
  • Phone: 586-469-7629
  • Fax: 586-469-7662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number6803086323
License Number StateMI

VIII. Authorized Official

Name: KELLY LYNN MALICKI
Title or Position: CASE MANAGER II
Credential: BS, SST
Phone: 586-466-6218