Provider Demographics
NPI:1104073592
Name:THE CENTRE
Entity type:Organization
Organization Name:THE CENTRE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:COLCLOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:251-625-0118
Mailing Address - Street 1:1290 MAIN ST STE E
Mailing Address - Street 2:
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-8624
Mailing Address - Country:US
Mailing Address - Phone:251-625-0118
Mailing Address - Fax:251-625-0116
Practice Address - Street 1:1290 MAIN ST STE E
Practice Address - Street 2:
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526-8624
Practice Address - Country:US
Practice Address - Phone:251-625-0118
Practice Address - Fax:251-625-0116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-27
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALLPC 111 AL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL515 92982OtherBLUE CROSS
AL515 92986OtherBLUE CROSS ROBERT COLCLOUGH