Healthcare Provider Details

I. General information

NPI: 1265912281
Provider Name (Legal Business Name): COMMUNITY BEHAVIORAL HEALTH AUTHORITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2018
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3721 W MICHIGAN AVE STE 200
LANSING MI
48917-3600
US

IV. Provider business mailing address

3721 W MICHIGAN AVE STE 200
LANSING MI
48917-3600
US

V. Phone/Fax

Practice location:
  • Phone: 517-515-6176
  • Fax:
Mailing address:
  • Phone: 517-323-4044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number State
# 12
Primary TaxonomyN
Taxonomy Code261QP2400X
TaxonomyPrison Health Clinic/Center
License Number
License Number State
# 13
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 14
Primary TaxonomyN
Taxonomy Code273R00000X
TaxonomyPsychiatric Hospital Unit
License Number
License Number State

VIII. Authorized Official

Name: MRS. CANDACE LYNN TILLERY
Title or Position: COO
Credential: LMSW
Phone: 517-242-5711