Healthcare Provider Details

I. General information

NPI: 1003878554
Provider Name (Legal Business Name): VAN BUREN COMMUNITY MENTAL HEALTH AUTHORITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2006
Last Update Date: 01/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 HAZEN ST STE C
PAW PAW MI
49079-0249
US

IV. Provider business mailing address

PO BOX 249 801 HAZEN ST STE C
PAW PAW MI
49079-0249
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. DEBRA HESS
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: CEO
Phone: 269-657-5574