Healthcare Provider Details

I. General information

NPI: 1679201271
Provider Name (Legal Business Name): SANFORD BEHAVIORAL HEALTH OUTPATIENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2022
Last Update Date: 08/29/2022
Certification Date: 08/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15146 16TH AVE
MARNE MI
49435-9605
US

IV. Provider business mailing address

15146 16TH AVE
MARNE MI
49435-9605
US

V. Phone/Fax

Practice location:
  • Phone: 844-776-9651
  • Fax:
Mailing address:
  • Phone: 844-776-9651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE ROBINSON
Title or Position: CREDENTIALING & CONTRACTING MANAGER
Credential:
Phone: 616-520-9074