Provider Demographics
NPI: | 1710015201 |
---|---|
Name: | ANDERSON CHEROKEE COMMUNITY ENRICHMENT SERVICES |
Entity Type: | Organization |
Organization Name: | ANDERSON CHEROKEE COMMUNITY ENRICHMENT SERVICES |
Other - Org Name: | ACCESS |
Other - Org Type: | Other Name |
Authorized Official - Title/Position: | REIMBURSEMENT COORDINATOR |
Authorized Official - Prefix: | |
Authorized Official - First Name: | DIANNA |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | STROM |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 903-589-9000 |
Mailing Address - Street 1: | 1011 COLLEGE AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | JACKSONVILLE |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 75766-3307 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 903-589-9000 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1011 COLLEGE AVE |
Practice Address - Street 2: | |
Practice Address - City: | JACKSONVILLE |
Practice Address - State: | TX |
Practice Address - Zip Code: | 75766 |
Practice Address - Country: | US |
Practice Address - Phone: | 903-589-9000 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-02-28 |
Last Update Date: | 2022-07-15 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TX | 17029 | 101Y00000X |
TX | 63332 | 101YM0800X |
101YP2500X, 103T00000X, 261QM0801X, 261QR0405X, 363A00000X, 363LF0000X, 363LP0808X, 261QM0801X | ||
TX | 674004 | 163WC1500X |
TX | 618031 | 163WC1500X |
TX | 051913 | 164X00000X |
TX | H5197 | 2084P0800X |
TX | K2150 | 2084P0800X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 261QM0801X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | Group - Multi-Specialty |
No | 101Y00000X | Behavioral Health & Social Service Providers | Counselor | Group - Multi-Specialty | |
No | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health | Group - Multi-Specialty |
No | 101YP2500X | Behavioral Health & Social Service Providers | Counselor | Professional | Group - Multi-Specialty |
No | 103T00000X | Behavioral Health & Social Service Providers | Psychologist | Group - Multi-Specialty | |
No | 163WC1500X | Nursing Service Providers | Registered Nurse | Community Health | Group - Multi-Specialty |
No | 164X00000X | Nursing Service Providers | Licensed Vocational Nurse | Group - Multi-Specialty | |
No | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Multi-Specialty |
No | 261QR0405X | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | Group - Multi-Specialty |
No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | Group - Multi-Specialty |
No | 363LP0808X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psychiatric/Mental Health | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TX | 00T09Z | Other | BLUE CROSS BLUE SHIELD |
TX | 111411803 | Medicaid |