Basic Information
| Provider Information | |||||||||
| NPI: | 1316154503 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PANHANDLE MENTAL HEALTH CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PMHC-COMMUNITY SUPPORT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4110 AVENUE D | ||||||||
| Address2: | |||||||||
| City: | SCOTTSBLUFF | ||||||||
| State: | NE | ||||||||
| PostalCode: | 693614650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3086353171 | ||||||||
| FaxNumber: | 3086357026 | ||||||||
| Practice Location | |||||||||
| Address1: | 18 W 16TH ST | ||||||||
| Address2: | |||||||||
| City: | SCOTTSBLUFF | ||||||||
| State: | NE | ||||||||
| PostalCode: | 693613154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3086324412 | ||||||||
| FaxNumber: | 3086322326 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2007 | ||||||||
| LastUpdateDate: | 01/27/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RICHARDS | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3086353171 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | NE | Y | Agencies | Case Management |
No ID Information.