=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396056024
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PINES BEHAVIORAL HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2010
-----------------------------------------------------
Last Update Date | 06/28/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 274 E CHICAGO ST
-----------------------------------------------------
City | COLDWATER
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49036-2041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-279-5377
-----------------------------------------------------
Fax | 517-279-5497
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 ORLEANS BLVD
-----------------------------------------------------
City | COLDWATER
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49036-1767
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-279-5377
-----------------------------------------------------
Fax | 517-279-5497
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOCIAL WORKER
-----------------------------------------------------
Name | MRS. KERRY ANN MELLO
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 517-279-5377
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 273R00000X
-----------------------------------------------------
Taxonomy Name | Psychiatric Hospital Unit
-----------------------------------------------------
License Number | 6801085437
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------