Provider Demographics
NPI:1528208428
Name:CENTENNIAL MENTAL HEALTH CENTER
Entity Type:Organization
Organization Name:CENTENNIAL MENTAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
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 1:365 W 2ND ST
Practice Address - Street 2:
Practice Address - City:WRAY
Practice Address - State:CO
Practice Address - Zip Code:80758-1009
Practice Address - Country:US
Practice Address - Phone:970-522-4549
Practice Address - Fax:970-522-6898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-05
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO150153251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04110094Medicaid
COC-39009Medicare UPIN