Provider Demographics
NPI:1316545940
Name:RED MESA OUTPATIENT TREATMENT CENTER
Entity Type:Organization
Organization Name:RED MESA OUTPATIENT TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BEHAVIORAL HEALTH DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SIDNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:PSY D
Authorized Official - Phone:505-368-1438
Mailing Address - Street 1:PO BOX 1830
Mailing Address - Street 2:
Mailing Address - City:SHIPROCK
Mailing Address - State:NM
Mailing Address - Zip Code:87420-1830
Mailing Address - Country:US
Mailing Address - Phone:505-368-1438
Mailing Address - Fax:505-368-1461
Practice Address - Street 1:US HWY 160 & NAVAJO ROUTE 35
Practice Address - Street 2:
Practice Address - City:RED MESA
Practice Address - State:AZ
Practice Address - Zip Code:86514
Practice Address - Country:US
Practice Address - Phone:505-368-1438
Practice Address - Fax:505-368-1461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-15
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health