{
"Npi": {
"NPI": "1104715036",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "Y",
"ParentOrgLBN": "COMMUNITY MENTAL HEALTH SERVICES OF ST JOSEPH COUNTY",
"ParentOrgTIN": null,
"OrgName": "COMMUNITY MENTAL HEALTH SERVICES OF ST JOSEPH COUNTY",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "677 E MAIN ST STE A",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "CENTREVILLE",
"MailingAddressStateName": "MI",
"MailingAddressPostalCode": "49032-8525",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "269-467-1000",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "677 E MAIN ST STE A",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "CENTREVILLE",
"PracticeLocationAddressStateName": "MI",
"PracticeLocationAddressPostalCode": "49032-8525",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "269-467-1000",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "07/03/2025",
"LastUpdateDate": "07/03/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "BULLOCK",
"AuthorizedOfficialFirstName": "CAMERON",
"AuthorizedOfficialMiddleName": "EDWARD BREWSTER",
"AuthorizedOfficialTitle": "CHIEF EXECUTIVE OFFICER",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "269-467-1001",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "251S00000X",
"TaxonomyName": "Community/Behavioral Health Agency",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}