| NPI | 1790166353 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | HEATHER LYN VIDETO Credentialing 269-344-0202 |
| Organization Subpart ? | No |
| Primary Taxonomy | 251S00000X |
| Additional Taxonomies | 261QM0801X Clinic/Center, Mental Health (Including Community Mental Health Center) |
| 261QM0850X Clinic/Center, Adult Mental Health | |
| Enumeration Date | 2015-06-09 |
| Last Update Date | 2021-12-02 |