Basic Information
| Provider Information | |||||||||
| NPI: | 1417197757 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTENNIAL MENTAL HELATH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 211 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | STERLING | ||||||||
| State: | CO | ||||||||
| PostalCode: | 807513168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9705224549 | ||||||||
| FaxNumber: | 9705226898 | ||||||||
| Practice Location | |||||||||
| Address1: | 211 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | STERLING | ||||||||
| State: | CO | ||||||||
| PostalCode: | 807513168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9705224549 | ||||||||
| FaxNumber: | 9705226898 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2009 | ||||||||
| LastUpdateDate: | 07/15/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HICKMAN | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9705224549 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
| NPICertificationDate: | 07/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 150153 | CO | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 04110094 | 05 | CO | MEDICAID |