Basic Information
| Provider Information | |||||||||
| NPI: | 1063575165 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEAST MENTAL HEALTH CENTER, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3810 WINCHESTER RD | ||||||||
| Address2: | SOUTHEAST MENTAL HEALTH CENTER | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381186045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9013691420 | ||||||||
| FaxNumber: | 9013691433 | ||||||||
| Practice Location | |||||||||
| Address1: | 2579 DOUGLASS AVE | ||||||||
| Address2: | SOUTHEAST MENTAL HEALTH CENTER | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381142532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9013691484 | ||||||||
| FaxNumber: | 9013127572 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | LAWRENCE | ||||||||
| AuthorizedOfficialFirstName: | OWEN | ||||||||
| AuthorizedOfficialMiddleName: | EUGENE | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9013691420 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | 762 | TN | Y | Suppliers | Pharmacy | Clinic Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 399596 | 05 | TN | MEDICAID |