Basic Information
| Provider Information | |||||||||
| NPI: | 1992846752 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEAST KANSAS MENTAL HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1106 S 9TH ST | ||||||||
| Address2: | |||||||||
| City: | HUMBOLDT | ||||||||
| State: | KS | ||||||||
| PostalCode: | 667481934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6204732241 | ||||||||
| FaxNumber: | 6204733334 | ||||||||
| Practice Location | |||||||||
| Address1: | 1106 S 9TH ST | ||||||||
| Address2: | |||||||||
| City: | HUMBOLDT | ||||||||
| State: | KS | ||||||||
| PostalCode: | 667481934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6204732241 | ||||||||
| FaxNumber: | 6204733334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | CHASE | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | F. | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6203658641 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 025 | KS | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 006901 | 01 | KS | BLUE SHIELD | OTHER |