Basic Information
| Provider Information | |||||||||
| NPI: | 1487829966 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MENTAL HEALTH BOARD OF CHILTON AND SHELBY COUNTIES INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHILTON-SHELBY MENTAL HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 689 | ||||||||
| Address2: | |||||||||
| City: | CALERA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350400689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2057558800 | ||||||||
| FaxNumber: | 2057558882 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | CLANTON | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350452332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2057558800 | ||||||||
| FaxNumber: | 2057558882 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2008 | ||||||||
| LastUpdateDate: | 04/25/2008 | ||||||||
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| AuthorizedOfficialLastName: | CRAWFORD | ||||||||
| AuthorizedOfficialFirstName: | MELODIE | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2056684308 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MENTAL HEALTH BOARD OF CHILTON AND SHELBY COUNTIES, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 515-11686 | 01 | AL | BLUE CROSS/BLUE SHIELD ALL KIDS PLUS | OTHER |