MEDICARE: SOUTHEAST MENTAL HEALTH CENTER, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0002X	Clinic Pharmacy	762	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063575165
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHEAST MENTAL HEALTH CENTER, INC

Provider Business Mailing Address
First Line	:	3810 WINCHESTER RD
Second Line	:	SOUTHEAST MENTAL HEALTH CENTER
City	:	MEMPHIS
State	:	TN
Zip	:	38118-6045
Country	:	US
Telephone Number	:	901-369-1420
Fax Number	:	901-369-1433

Provider Business Practice Location Address
First Line	:	2579 DOUGLASS AVE
Second Line	:	SOUTHEAST MENTAL HEALTH CENTER
City	:	MEMPHIS
State	:	TN
Zip	:	38114-2532
Country	:	US
Telephone Number	:	901-369-1484
Fax Number	:	901-312-7572

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. OWEN EUGENE LAWRENCE
Credential	:	MA
Telephone Number	:	901-369-1420

Provider Enumeration Date	:	12/19/2006
Last Update Date	:	08/22/2020

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