Healthcare Provider Details

I. General information

NPI: 1467414771
Provider Name (Legal Business Name): SOUTHEAST KANSAS MENTAL HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2006
Last Update Date: 11/12/2025
Certification Date: 11/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1106 S 9TH ST
HUMBOLDT KS
66748-1934
US

IV. Provider business mailing address

1106 S 9TH ST P.O. BOX 39
HUMBOLDT KS
66748-1934
US

V. Phone/Fax

Practice location:
  • Phone: 620-473-2241
  • Fax: 620-473-3334
Mailing address:
  • Phone: 620-473-2241
  • Fax: 620-473-3334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number025
License Number StateKS

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier006901
Identifier TypeOTHER
Identifier StateKS
Identifier IssuerBLUE SHIELD
# 2
Identifier3000391474
Identifier TypeMEDICAID
Identifier StateKS
Identifier Issuer

VIII. Authorized Official

Name: SHANA BENNETT
Title or Position: DIRECTOR OF OFFICE OPERATIONS
Credential:
Phone: 620-365-8641