Basic Information
| Provider Information | |||||||||
| NPI: | 1700989589 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CULLMAN AREA MENTAL HEALTH AUTHORITY, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MENTAL HEALTHCARE OF CULLMAN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2186 | ||||||||
| Address2: | |||||||||
| City: | CULLMAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350562186 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567344688 | ||||||||
| FaxNumber: | 2567365638 | ||||||||
| Practice Location | |||||||||
| Address1: | 1909 COMMERCE AVE | ||||||||
| Address2: | |||||||||
| City: | CULLMAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350556151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567344688 | ||||||||
| FaxNumber: | 2567365638 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2006 | ||||||||
| LastUpdateDate: | 08/13/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VANDYKE | ||||||||
| AuthorizedOfficialFirstName: | CHRIS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2567344688 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | MA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 08814 | 01 | AL | PPO CONTRACT | OTHER | 51008814 | 01 | AL | ALL KIDS | OTHER | 590000025 | 05 | AL | MEDICAID | 529923460 | 05 | AL | MEDICAID | 051008814 | 01 | AL | BLUE CROSS BLUE SHIELD PEEHIP | OTHER | 590034025 | 05 | AL | MEDICAID | 051008814 | 01 | AL | BLUE CROSS BLUE SHIELD SEIB | OTHER | 330000025 | 05 | AL | MEDICAID | 330034025 | 05 | AL | MEDICAID |