Healthcare Provider Details

I. General information

NPI: 1467590406
Provider Name (Legal Business Name): BLUE WATER MENTAL HEALTH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 12/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 S MAIN ST
YALE MI
48097-3316
US

IV. Provider business mailing address

1501 KRAFFT RD
FORT GRATIOT MI
48059-3565
US

V. Phone/Fax

Practice location:
  • Phone: 810-985-5125
  • Fax: 810-985-5127
Mailing address:
  • Phone: 810-985-5125
  • Fax: 810-985-5127

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MRS. LINDA A. LIETHEN
Title or Position: EXECUTIVE DIRECTOR
Credential: LLP
Phone: 810-985-5125