=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073044004
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHEAST COMMUNITY MENTAL HEALTH CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2017
-----------------------------------------------------
Last Update Date | 08/09/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1455 S 4TH ST
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43207-1011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-327-9008
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1455 S 4TH ST
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43207-1011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-327-9008
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOCIAL WORKER
-----------------------------------------------------
Name | BRITTNEY DANGLER
-----------------------------------------------------
Credential | LISW
-----------------------------------------------------
Telephone | 614-444-0800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | S.1440478
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------