MEDICARE: NORTHERN LAKES COMMUNITY MENTAL HEALTH AUTHORITY

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	0750910830	OTHER	MI	BCBSM OPC CADILLAC

General Provider Information

NPI Number	:	1669572657
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHERN LAKES COMMUNITY MENTAL HEALTH AUTHORITY

Provider Business Mailing Address
First Line	:	105 HALL ST
Second Line	:	SUITE A
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-2288
Country	:	US
Telephone Number	:	231-922-4850
Fax Number	:	231-935-3856

Provider Business Practice Location Address
First Line	:	105 HALL ST
Second Line	:	SUITE A
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-2288
Country	:	US
Telephone Number	:	231-922-4850
Fax Number	:	231-935-3856

Authorized Official
Title or Position	:	COO
Name	:	NANCY STEVENSON
Credential	:
Telephone Number	:	231-922-4850

Provider Enumeration Date	:	09/22/2006
Last Update Date	:	11/28/2023

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Directions to “NORTHERN LAKES COMMUNITY MENTAL HEALTH AUTHORITY ” Practice Location

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