MEDICARE: TRUENORTH CCM, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	6401012384	MI

General Provider Information

NPI Number	:	1225580772
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRUENORTH CCM, INC.

Provider Business Mailing Address
First Line	:	2945 HANSEN RD
Second Line	:
City	:	WEST BRANCH
State	:	MI
Zip	:	48661-9317
Country	:	US
Telephone Number	:	989-345-5440
Fax Number	:

Provider Business Practice Location Address
First Line	:	2945 HANSEN RD
Second Line	:
City	:	WEST BRANCH
State	:	MI
Zip	:	48661-9317
Country	:	US
Telephone Number	:	989-345-5440
Fax Number	:

Authorized Official
Title or Position	:	MINISTRY DIRECTOR
Name	:	MRS. KRISTINE MARIE GOODROE
Credential	:	MA, LPC
Telephone Number	:	989-345-5440

Provider Enumeration Date	:	11/01/2016
Last Update Date	:	11/01/2016

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