Healthcare Provider Details

I. General information

NPI: 1629161567
Provider Name (Legal Business Name): HIAWATHA COMMUNITY BEHAVIORAL HEALTH AUTHORITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 11/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3865 S MACKINAC TRL
SAULT SAINTE MARIE MI
49783-9286
US

IV. Provider business mailing address

125 N LAKE ST
MANISTIQUE MI
49854-1234
US

V. Phone/Fax

Practice location:
  • Phone: 906-632-2805
  • Fax: 906-632-1163
Mailing address:
  • Phone: 906-341-2144
  • Fax: 906-341-5793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. SAMUEL HARMA
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 906-341-2144