NPIMap

Organization Active NPI

Southern Area Behavioral Healthcare LLC

  • Psychiatry Physician
  • Dallas, TX
National Provider Identifier
1396973772
Registry record updated Jan 3, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatry PhysicianTaxonomy code 2084P0800X
Legal business name
SOUTHERN AREA BEHAVIORAL HEALTHCARE LLC
Practice address
4215 Gannon LN
Dallas, TX 75237-2914
Phone
(972) 283-9090
Fax
(972) 499-0367
NPI assigned
Jun 24, 2009
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 3, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Kenneth R Medlock
Title
Chief Executive Officer
Phone
(972) 283-9090

Specialties & licenses 8

Specialty (taxonomy)CodeLicenseStatePrimary
Professional CounselorGroup: 193200000X MULTI-SPECIALTY GROUP 101YP2500X
Case Manager/Care CoordinatorGroup: 193200000X MULTI-SPECIALTY GROUP 171M00000X
Psychiatry PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2084P0800X Primary
Case Management Agency 251B00000X
Mental Health Clinic/Center (Including Community Mental Health Center) 261QM0801X
Adult Mental Health Clinic/Center 261QM0850X
Adolescent and Children Mental Health Clinic/Center 261QM0855X
Multi-Specialty Clinic/Center 261QM1300X

Addresses

Primary practice location

4215 Gannon LN
Dallas, TX 75237-2914

Mailing address

4215 Gannon LN
Dallas, TX 75237-2914
Phone (972) 283-9090

Other practice location 1

3001 Al Lipscomb Way
Dallas, TX 75215-1702
Phone (972) 283-9090

Other practice location 2

110 W Grove St
Kaufman, TX 75142-2033
Phone (972) 283-9090

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TX

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20150407000552 TX Part B Supplier - Clinic/Group Practice 1658699434 Receives reassigned benefits from 9 practitioners
Practice locations: Dallas, TX

National Provider Directory

National Provider Directory

Locations

4333 Gannon Ln
Ste 101
Dallas, TX 75237
Phone (972) 283-9090

110 W Grove St
Kaufman, TX 75142
Phone (972) 283-9090

Practitioners & affiliated clinicians

Practitioners 10

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1245801600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1704240000000",
    "number": "1396973772",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4215 GANNON LN",
            "city": "DALLAS",
            "state": "TX",
            "postal_code": "752372914",
            "telephone_number": "972-283-9090",
            "fax_number": "972-499-0367"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4215 GANNON LN",
            "city": "DALLAS",
            "state": "TX",
            "postal_code": "752372914",
            "telephone_number": "972-283-9090",
            "fax_number": "972-499-0367"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "3001 Al Lipscomb Way",
            "address_purpose": "LOCATION",
            "city": "Dallas",
            "state": "TX",
            "postal_code": "752151702",
            "country_code": "US",
            "telephone_number": "972-283-9090",
            "fax_number": "972-499-0367",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "110 W Grove St",
            "address_purpose": "LOCATION",
            "city": "Kaufman",
            "state": "TX",
            "postal_code": "751422033",
            "country_code": "US",
            "telephone_number": "972-283-9090",
            "fax_number": "972-499-0367",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "SOUTHERN AREA BEHAVIORAL HEALTHCARE LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-06-24",
        "last_updated": "2024-01-03",
        "certification_date": "2024-01-03",
        "status": "A",
        "authorized_official_last_name": "MEDLOCK",
        "authorized_official_first_name": "KENNETH",
        "authorized_official_middle_name": "R",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "972-283-9090"
    },
    "taxonomies": [
        {
            "code": "101YP2500X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Professional",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "171M00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Case Manager/Care Coordinator",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "251B00000X",
            "taxonomy_group": "",
            "desc": "Case Management",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QM0801X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Mental Health (Including Community Mental Health Center)",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QM0850X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Adult Mental Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QM0855X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Adolescent and Children Mental Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QM1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Multi-Specialty",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Dallas, TX

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 3, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.