1609194448 NPI number — SOUTHEAST MISSOURI BEHAVIORAL HEALTH

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609194448 NPI number — SOUTHEAST MISSOURI BEHAVIORAL HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEAST MISSOURI BEHAVIORAL HEALTH
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SOUTHEAST MISSOURI COMMUNITY TREATMENT CENTER
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609194448
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/04/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
512 E MAIN ST
Provider Second Line Business Mailing Address:
PO BOX 506
Provider Business Mailing Address City Name:
PARK HILLS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63601-2624
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-431-0554
Provider Business Mailing Address Fax Number:
573-431-5205

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
216 PIEDMONT AVE STE 304
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PIEDMONT
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63957-1017
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-223-2734
Provider Business Practice Location Address Fax Number:
573-223-2764
Provider Enumeration Date:
05/04/2010

Additional Information

Authorized Official

Authorized Official Last Name:
PRATTE
Authorized Official First Name:
BARRON
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRESIDENT CEO
Authorized Official Telephone Number:
573-431-0554

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ADA-SDA4209122 . This is a "PR PLUS CONTRACT PROVIDER WITH DMH" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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