=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033835707
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACES PEDIATRIC BEHAVIORAL HEALTH PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2022
-----------------------------------------------------
Last Update Date | 01/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10823 N STRAITS HWY STE B
-----------------------------------------------------
City | CHEBOYGAN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49721-9077
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-268-1149
-----------------------------------------------------
Fax | 231-268-3369
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 122
-----------------------------------------------------
City | CHEBOYGAN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49721-0122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-268-1149
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL DIRECTOR
-----------------------------------------------------
Name | MS. TAMYRA N COOPER
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 231-268-1149
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------