MEDICARE: FENTON BEHAVIORAL HEALTH SERVICES

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	250045	MI

General Provider Information

NPI Number	:	1427390178
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FENTON BEHAVIORAL HEALTH SERVICES

Provider Business Mailing Address
First Line	:	1122 N LEROY ST STE C
Second Line	:
City	:	FENTON
State	:	MI
Zip	:	48430-2789
Country	:	US
Telephone Number	:	810-629-4224
Fax Number	:	810-629-4234

Provider Business Practice Location Address
First Line	:	1122 N LEROY ST STE C
Second Line	:
City	:	FENTON
State	:	MI
Zip	:	48430-2789
Country	:	US
Telephone Number	:	810-629-4224
Fax Number	:	810-629-4234

Authorized Official
Title or Position	:	OWNER/OPERATOR/PRACTITIONER
Name	:	MR. DUANE EDWARD LAGUIRE-QUINN
Credential	:	LMSW, ACSW
Telephone Number	:	810-629-4224

Provider Enumeration Date	:	03/20/2013
Last Update Date	:	03/20/2013

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