Provider Demographics
NPI:1710933445
Name:NORTHEAST IOWA MENTAL HEALTH CENTER
Entity Type:Organization
Organization Name:NORTHEAST IOWA MENTAL HEALTH CENTER
Other - Org Name:NORTHEAST IOWA BEHAVIORAL HEALTH, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARCIA
Authorized Official - Middle Name:
Authorized Official - Last Name:OLTROGGE
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:563-382-3649
Mailing Address - Street 1:PO BOX 349
Mailing Address - Street 2:905 MONTGOMERY ST.
Mailing Address - City:DECORAH
Mailing Address - State:IA
Mailing Address - Zip Code:52101-0349
Mailing Address - Country:US
Mailing Address - Phone:563-382-3649
Mailing Address - Fax:563-382-8183
Practice Address - Street 1:905 MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:DECORAH
Practice Address - State:IA
Practice Address - Zip Code:52101-2325
Practice Address - Country:US
Practice Address - Phone:563-382-3649
Practice Address - Fax:563-382-8183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IANONE261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0074559Medicaid
IA07455Medicare ID - Type UnspecifiedIDENTIFICATION NUMBER