Provider Demographics
NPI:1649428855
Name:CHILDREN'S COMMUNITY MENTAL HEALTH CLINIC
Entity type:Organization
Organization Name:CHILDREN'S COMMUNITY MENTAL HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMPREHENSIVE COMMUNITY SUPPORT SER
Authorized Official - Prefix:MR
Authorized Official - First Name:SOLOMON
Authorized Official - Middle Name:T
Authorized Official - Last Name:FOULK
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:505-342-3799
Mailing Address - Street 1:5100 2ND ST NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-4009
Mailing Address - Country:US
Mailing Address - Phone:505-342-3799
Mailing Address - Fax:505-342-3758
Practice Address - Street 1:5100 2ND ST NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-4009
Practice Address - Country:US
Practice Address - Phone:505-342-3799
Practice Address - Fax:505-342-3758
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BERNALILLO COUNTY JUVENILE DETENTION YOUTH SERVICES CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-29
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM171M00000X251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMVNM00719NOMedicaid