Healthcare Provider Details

I. General information

NPI: 1063575165
Provider Name (Legal Business Name): SOUTHEAST MENTAL HEALTH CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2579 DOUGLASS AVE SOUTHEAST MENTAL HEALTH CENTER
MEMPHIS TN
38114-2532
US

IV. Provider business mailing address

3810 WINCHESTER RD SOUTHEAST MENTAL HEALTH CENTER
MEMPHIS TN
38118-6045
US

V. Phone/Fax

Practice location:
  • Phone: 901-369-1484
  • Fax: 901-312-7572
Mailing address:
  • Phone: 901-369-1420
  • Fax: 901-369-1433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number762
License Number StateTN

VIII. Authorized Official

Name: MR. OWEN EUGENE LAWRENCE
Title or Position: EXECUTIVE DIRECTOR
Credential: MA
Phone: 901-369-1420