Provider Demographics
NPI:1659313393
Name:MENTAL HEALTH BD OF BIBB PICKENS AND TUSCALOOSA COUNTIES
Entity Type:Organization
Organization Name:MENTAL HEALTH BD OF BIBB PICKENS AND TUSCALOOSA COUNTIES
Other - Org Name:INDIAN RIVERS MHC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:
Authorized Official - Last Name:THRASHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-391-3131
Mailing Address - Street 1:PO BOX 2190
Mailing Address - Street 2:2209 9TH STREET
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35403-2190
Mailing Address - Country:US
Mailing Address - Phone:205-391-3131
Mailing Address - Fax:205-391-3137
Practice Address - Street 1:2209 9TH ST
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35401-2300
Practice Address - Country:US
Practice Address - Phone:205-391-3131
Practice Address - Fax:205-391-3137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL330000024Medicaid
AL330034024Medicaid
AL528700510Medicaid
AL590000024Medicaid
AL51008111OtherBCBS OF AL
AL528700510Medicaid