Provider Demographics
NPI:1063575165
Name:SOUTHEAST MENTAL HEALTH CENTER, INC
Entity type:Organization
Organization Name:SOUTHEAST MENTAL HEALTH CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:OWEN
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:LAWRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:901-369-1420
Mailing Address - Street 1:3810 WINCHESTER RD
Mailing Address - Street 2:SOUTHEAST MENTAL HEALTH CENTER
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38118-6045
Mailing Address - Country:US
Mailing Address - Phone:901-369-1420
Mailing Address - Fax:901-369-1433
Practice Address - Street 1:2579 DOUGLASS AVE
Practice Address - Street 2:SOUTHEAST MENTAL HEALTH CENTER
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38114-2532
Practice Address - Country:US
Practice Address - Phone:901-369-1484
Practice Address - Fax:901-312-7572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7623336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN399596Medicaid
TN399596Medicaid