Provider Demographics
NPI:1023176054
Name:SOUTHEAST MISSOURI BEHAVIORAL HEALTH
Entity type:Organization
Organization Name:SOUTHEAST MISSOURI BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BARRON
Authorized Official - Middle Name:E
Authorized Official - Last Name:PRATTE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:573-756-5749
Mailing Address - Street 1:5536 HWY 32
Mailing Address - Street 2:PO DRAWER 459
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-7357
Mailing Address - Country:US
Mailing Address - Phone:573-756-5749
Mailing Address - Fax:573-431-5205
Practice Address - Street 1:5536 STATE HIGHWAY 32
Practice Address - Street 2:PO DRAWER 459
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-7357
Practice Address - Country:US
Practice Address - Phone:573-756-5749
Practice Address - Fax:573-756-7451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO866204803Medicaid
MO15-18796OtherUBH PROVIDER #
MO12318Medicare ID - Type UnspecifiedMEDICARE PROVIDER #