Provider Demographics
NPI:1922374826
Name:CHEYENNE RIVER SIOUX TRIBE BEHAVORIAL HEALTH
Entity Type:Organization
Organization Name:CHEYENNE RIVER SIOUX TRIBE BEHAVORIAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TRIBAL HEALTH CEO
Authorized Official - Prefix:
Authorized Official - First Name:RAMONA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:605-964-0785
Mailing Address - Street 1:PO BOX 590
Mailing Address - Street 2:
Mailing Address - City:EAGLE BUTTE
Mailing Address - State:SD
Mailing Address - Zip Code:57625-0590
Mailing Address - Country:US
Mailing Address - Phone:605-964-0788
Mailing Address - Fax:
Practice Address - Street 1:24276 166TH STREET AIRPORT ROAD
Practice Address - Street 2:BOX 1007
Practice Address - City:EAGLE BUTTE
Practice Address - State:SD
Practice Address - Zip Code:57625
Practice Address - Country:US
Practice Address - Phone:605-964-0788
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-26
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD126103T00000X
251S00000X, 261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5546290Medicaid