Provider Demographics
NPI:1679201271
Name:SANFORD BEHAVIORAL HEALTH OUTPATIENT LLC
Entity type:Organization
Organization Name:SANFORD BEHAVIORAL HEALTH OUTPATIENT LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING & CONTRACTING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-520-9074
Mailing Address - Street 1:15146 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:MARNE
Mailing Address - State:MI
Mailing Address - Zip Code:49435-9605
Mailing Address - Country:US
Mailing Address - Phone:844-776-9651
Mailing Address - Fax:
Practice Address - Street 1:15146 16TH AVE
Practice Address - Street 2:
Practice Address - City:MARNE
Practice Address - State:MI
Practice Address - Zip Code:49435-9605
Practice Address - Country:US
Practice Address - Phone:844-776-9651
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-11
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty