Basic Information
| Provider Information | |||||||||
| NPI: | 1699009944 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AVERA MCKENNAN | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AVERA MCKENNAN BEHAVIORAL HEALTH CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 E 21ST ST | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571051016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053226400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2412 S CLIFF AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571054031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053224079 | ||||||||
| FaxNumber: | 6053224080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2009 | ||||||||
| LastUpdateDate: | 09/18/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NORTON | ||||||||
| AuthorizedOfficialFirstName: | JULIE | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | VP/CFO | ||||||||
| AuthorizedOfficialTelephone: | 6053226375 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 10563 | SD | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.