Basic Information
| Provider Information | |||||||||
| NPI: | 1174690309 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PETERSBURG MENTAL HEALTH SERVICES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1309 | ||||||||
| Address2: | |||||||||
| City: | PETERSBURG | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998331309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077723332 | ||||||||
| FaxNumber: | 8888588850 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 NORTH NORDIC DRIVE | ||||||||
| Address2: | |||||||||
| City: | PETERSBURG | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998331309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077723332 | ||||||||
| FaxNumber: | 8888588850 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 07/22/2010 | ||||||||
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| AuthorizedOfficialLastName: | OHMER | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9077723332 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 282463 | AK | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | 282463 | AK | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 261QM0801X | 282463 | AK | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | DA1413 | 05 | AK | MEDICAID | MH1413 | 05 | AK | MEDICAID |