Provider Demographics
NPI:1609194448
Name:SOUTHEAST MISSOURI BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:SOUTHEAST MISSOURI BEHAVIORAL HEALTH
Other - Org Name:SOUTHEAST MISSOURI COMMUNITY TREATMENT CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BARRON
Authorized Official - Middle Name:E
Authorized Official - Last Name:PRATTE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:573-431-0554
Mailing Address - Street 1:512 E MAIN ST
Mailing Address - Street 2:PO BOX 506
Mailing Address - City:PARK HILLS
Mailing Address - State:MO
Mailing Address - Zip Code:63601-2624
Mailing Address - Country:US
Mailing Address - Phone:573-431-0554
Mailing Address - Fax:573-431-5205
Practice Address - Street 1:216 PIEDMONT AVE STE 304
Practice Address - Street 2:
Practice Address - City:PIEDMONT
Practice Address - State:MO
Practice Address - Zip Code:63957-1017
Practice Address - Country:US
Practice Address - Phone:573-223-2734
Practice Address - Fax:573-223-2764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-04
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOADA-SDA4209122OtherPR PLUS CONTRACT PROVIDER WITH DMH