Basic Information
Provider Information | |||||||||
NPI: | 1649637273 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HOUSTON COUNTY HEALTHCARE AUTHORITY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ALTACARE OUTPATIENT PSYCHIATRY AND COUNSELING | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1928 | ||||||||
Address2: |   | ||||||||
City: | DOTHAN | ||||||||
State: | AL | ||||||||
PostalCode: | 363021928 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3347938087 | ||||||||
FaxNumber: | 3346782895 | ||||||||
Practice Location | |||||||||
Address1: | 1450 ROSS CLARK CIR | ||||||||
Address2: | SUITE 400B | ||||||||
City: | DOTHAN | ||||||||
State: | AL | ||||||||
PostalCode: | 363014765 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3347944582 | ||||||||
FaxNumber: | 3346719877 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/27/2016 | ||||||||
LastUpdateDate: | 01/27/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MILLER | ||||||||
AuthorizedOfficialFirstName: | ROBERT | ||||||||
AuthorizedOfficialMiddleName: | DEREK | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 3347938087 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | HOUSTON COUNTY HEALTHCARE AUTHORITY | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor |   | 1041C0700X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 2084P0800X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.