Healthcare Provider Details

I. General information

NPI: 1710028576
Provider Name (Legal Business Name): SOUTHEAST KANSAS MENTAL HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 05/03/2024
Certification Date: 05/03/2024
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
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 TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier100098050D
Identifier TypeMEDICAID
Identifier StateKS
Identifier Issuer
# 2
Identifier006901
Identifier TypeOTHER
Identifier StateKS
Identifier IssuerBLUE SHIELD

VIII. Authorized Official

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