Provider Demographics
NPI:1376062976
Name:CENTENNIAL MENTAL HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:CENTENNIAL MENTAL HEALTH CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:L
Authorized Official - Last Name:HICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:970-522-4549
Mailing Address - Street 1:211 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:CO
Mailing Address - Zip Code:80751-3168
Mailing Address - Country:US
Mailing Address - Phone:970-522-4549
Mailing Address - Fax:970-522-6898
Practice Address - Street 1:650 E. WALNUT
Practice Address - Street 2:UNIT C
Practice Address - City:ELIZABETH
Practice Address - State:CO
Practice Address - Zip Code:80107
Practice Address - Country:US
Practice Address - Phone:303-646-4519
Practice Address - Fax:303-646-4451
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTENNIAL MENTAL HEALTH CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-09-14
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1145-04261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder