Healthcare Provider Details

I. General information

NPI: 1346859642
Provider Name (Legal Business Name): NEW BEGINNINGS OUTPATIENT THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2020
Last Update Date: 11/24/2020
Certification Date: 11/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 E LAKESHORE DR STE 102
MANISTIQUE MI
49854-1692
US

IV. Provider business mailing address

601 E LAKESHORE DR STE 102
MANISTIQUE MI
49854-1692
US

V. Phone/Fax

Practice location:
  • Phone: 906-869-4350
  • Fax:
Mailing address:
  • Phone: 906-869-4350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AUSTIN NICHOLE MCDONOUGH
Title or Position: OUTPATIENT THERAPIST
Credential: LMSW
Phone: 906-869-4350