Provider Demographics
NPI:1154612745
Name:ST. JOHN PROVIDENCE HEALTH SYSTEM
Entity type:Organization
Organization Name:ST. JOHN PROVIDENCE HEALTH SYSTEM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BEHAVIORAL HEALTH INTAKE CLINICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:POPE
Authorized Official - Suffix:
Authorized Official - Credentials:MA LPC
Authorized Official - Phone:586-573-5872
Mailing Address - Street 1:11800 EAST TWELVE MILE ROAD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093
Mailing Address - Country:US
Mailing Address - Phone:586-573-5872
Mailing Address - Fax:586-573-5583
Practice Address - Street 1:11800 E 12 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3472
Practice Address - Country:US
Practice Address - Phone:586-573-5872
Practice Address - Fax:586-573-5583
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. JOHN PROVIDENCE HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-04-29
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401007085282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital