Basic Information
| Provider Information | |||||||||
| NPI: | 1356310585 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL COUNTIES CENTER FOR MENTAL HEALTH & MENTAL RETARDATION SRVS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 304 S 22ND ST | ||||||||
| Address2: | |||||||||
| City: | TEMPLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765014726 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 304 S 22ND ST | ||||||||
| Address2: | |||||||||
| City: | TEMPLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765014726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2542987000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2006 | ||||||||
| LastUpdateDate: | 02/10/2022 | ||||||||
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| AuthorizedOfficialLastName: | WARDELL | ||||||||
| AuthorizedOfficialFirstName: | JOHNNETTE | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2542987007 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 1041C0700X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 171M00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator | 251B00000X | N | Agencies | Case Management | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 101YM0800X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 029168401 | 05 | TX | MEDICAID | 081771001 | 05 | TX | MEDICAID | 121984202 | 05 | TX | MEDICAID | 121984201 | 05 | TX | MEDICAID | 151116401 | 05 | TX | MEDICAID |