Organization Name: | BLUE WATER MENTAL HEALTH CLINIC |
NPI Number: | 1174924864 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | LINDA A LIETHEN (EXECUTIVE DIRECTOR) |
Mailing Address: | 1501 Krafft Rd Fort Gratiot |
State: | MI US |
Postal Code: | 480593565 |
Phone Number: | 8109855125 |
Fax Number: | 8109855127 |
NPI Enumeration Date: | 09/12/2014 |
NPI Last Update Date: | 09/12/2014 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 103TC0700X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | N |
State: | |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Psychologist |
Taxonomy Specialization: | Clinical |
Taxonomy Definition: |