Healthcare Provider Details

I. General information

NPI: 1578082053
Provider Name (Legal Business Name): CENTENNIAL MENTAL HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2017
Last Update Date: 07/15/2021
Certification Date: 07/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 S ASH ST
YUMA CO
80759-1903
US

IV. Provider business mailing address

211 W MAIN ST
STERLING CO
80751-3168
US

V. Phone/Fax

Practice location:
  • Phone: 970-848-5412
  • Fax: 970-848-2414
Mailing address:
  • Phone: 970-522-4549
  • Fax: 970-522-6898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number1145-10
License Number StateCO

VIII. Authorized Official

Name: ELIZABETH L HICKMAN
Title or Position: EXECUTIVE DIRECTOR
Credential: PHD
Phone: 970-522-4549