Basic Information
| Provider Information | |||||||||
| NPI: | 1225663545 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTENNIAL MENTAL HELATH CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 211 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | STERLING | ||||||||
| State: | CO | ||||||||
| PostalCode: | 807513168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9705224549 | ||||||||
| FaxNumber: | 9705229544 | ||||||||
| Practice Location | |||||||||
| Address1: | 80 EAST FIRST | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | CHEYENNE WELLS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 808100000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193468183 | ||||||||
| FaxNumber: | 7193460292 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2020 | ||||||||
| LastUpdateDate: | 07/15/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LYNN | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9705711266 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CENTENNIAL MENTAL HEALTH CENTER, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
No ID Information.