Provider Demographics
NPI:1740659804
Name:TOTAH BEHAVIORAL HEALTH AUTHORITY
Entity type:Organization
Organization Name:TOTAH BEHAVIORAL HEALTH AUTHORITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMMUNITY SUPPORT WORKER
Authorized Official - Prefix:
Authorized Official - First Name:URIAH
Authorized Official - Middle Name:DIXON
Authorized Official - Last Name:SIMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-564-4804
Mailing Address - Street 1:PO BOX 5190
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87499-5190
Mailing Address - Country:US
Mailing Address - Phone:505-564-4804
Mailing Address - Fax:505-564-4857
Practice Address - Street 1:1615 OJO COURT
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401
Practice Address - Country:US
Practice Address - Phone:505-564-4804
Practice Address - Fax:505-564-4857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-18
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM115889273251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM115889273OtherCOMMUNITY SUPPORT WORKER