Basic Information
| Provider Information | |||||||||
| NPI: | 1568495588 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARSHALL-JACKSON MENTAL HEALTH BD., INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MT. LAKES BEHAVIORAL HEALTHCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2409 HOMER CLAYTON DR | ||||||||
| Address2: | |||||||||
| City: | GUNTERSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 359762207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2565823203 | ||||||||
| FaxNumber: | 2565823216 | ||||||||
| Practice Location | |||||||||
| Address1: | 2409 HOMER CLAYTON DR | ||||||||
| Address2: | |||||||||
| City: | GUNTERSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 359762207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2565823203 | ||||||||
| FaxNumber: | 2565823216 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 10/18/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GARGIS | ||||||||
| AuthorizedOfficialFirstName: | MYRON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | INTERMIN EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2565824240 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 510081221 | 01 | AL | BCBS ALLKIDS | OTHER | 528400680 | 01 | AL | MCR/MCD CROSSOVER GROUP # | OTHER | 590000013 | 05 | AL | MEDICAID | 1568495588 | 01 | AL | UBH PROVIDER | OTHER | 330000013 | 05 | AL | MEDICAID | 330034013 | 05 | AL | MEDICAID |