Basic Information
Provider Information | |||||||||
NPI: | 1578082053 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CENTENNIAL MENTAL HEALTH CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 211 W MAIN ST | ||||||||
Address2: |   | ||||||||
City: | STERLING | ||||||||
State: | CO | ||||||||
PostalCode: | 807513168 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9705224549 | ||||||||
FaxNumber: | 9705226898 | ||||||||
Practice Location | |||||||||
Address1: | 215 S ASH ST | ||||||||
Address2: |   | ||||||||
City: | YUMA | ||||||||
State: | CO | ||||||||
PostalCode: | 807591903 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9708485412 | ||||||||
FaxNumber: | 9708482414 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/15/2017 | ||||||||
LastUpdateDate: | 07/15/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HICKMAN | ||||||||
AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 9705224549 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | CENTENNIAL MENTAL HEALTH CENTER, INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PHD | ||||||||
NPICertificationDate: | 07/15/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | 1145-10 | CO | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
No ID Information.