Healthcare Provider Details

I. General information

NPI: 1982916045
Provider Name (Legal Business Name): VAN BUREN COMMUNITY MENTAL HEALTH AUTHORITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2010
Last Update Date: 07/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57418 CR 681 SUITE C
HARTFORD MI
49057
US

IV. Provider business mailing address

P.O. BOX 249 801 HAZEN STREET SUITE C
PAW PAW MI
49079-0249
US

V. Phone/Fax

Practice location:
  • Phone: 269-621-6251
  • Fax: 269-621-6044
Mailing address:
  • Phone: 269-657-5574
  • Fax: 269-657-3474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. DEBRA L-R HESS
Title or Position: C.E.O.
Credential:
Phone: 269-657-5574