NPIMap

Organization Active NPI

State of Missouri

Doing business as Southeast MO Mental Health Center

  • Psychiatry Physician
  • Farmington, MO
National Provider Identifier
1437106705
Registry record updated Sep 3, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatry PhysicianTaxonomy code 2084P0800X
Legal business name
STATE OF MISSOURI
Doing business as
Southeast MO Mental Health Center
Practice address
1010 W Columbia St
Farmington, MO 63640-2902
Phone
(573) 218-6792
Fax
(573) 218-6703
NPI assigned
May 30, 2006
Last updated
Sep 3, 2020By the provider in NPPES
Organization subpart
Yes
Parent organization
STATE OF MISSOURIAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Sep 3, 2020

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

Authorized official

Name
Molly Jane Boeckmann
Title
Director Administrative Services
Phone
(573) 751-4055

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical Psychologist 103TC0700X NU
Clinical Social Worker 1041C0700X NU
Psychiatry Physician 2084P0800X NU Primary
General Practice Physician 208D00000X NU

Addresses

Primary practice location

1010 W Columbia St
Farmington, MO 63640-2902

Mailing address

1706 E Elm St
Jefferson City, MO 65101-4130
Phone (573) 751-3398

Other identifiers 1

IdentifierTypeStateIssuer
500490206MedicaidMO

Other names 1

  • Southeast MO Mental Health Center Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040218001002 MO Part B Supplier - Clinic/Group Practice 1456254226 Receives reassigned benefits from 23 practitioners
Practice locations: Farmington, MO

Other NPIs with the same Medicare PAC ID 11

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Western Missouri Mental Health Center104 organizations share this tax ID, including this one
Part of
Western Missouri Mental Health Center

Organizations with this tax ID in the same state 24

This tax ID family is large, so up to 24 of its organizations in the same state are linked here.

View all 24

Locations

1010 W Columbia St
Farmington, MO 63640
Phone (573) 218-6792

Ownership & related parties

All facility ownership & control disclosures 6

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Center for Behavioral MedicineKansas City, MO, CCN 264008 Hospital 5% Or Greater Direct Ownership Interest (100%) Jul 1, 1966
St Louis Forensic Treatment CenterSaint Louis, MO, CCN 264010 Hospital 5% Or Greater Direct Ownership Interest (100%) Jul 1, 1966
Southeast Missouri Mental Health CenterFarmington, MO, CCN 264005 Hospital 5% Or Greater Direct Ownership Interest (100%) Jul 1, 1966
Fulton State HospitalFulton, MO, CCN 264004 Hospital 5% Or Greater Direct Ownership Interest (100%) Jul 1, 1966
Northwest Missouri Psychiatric Rehabilitation CenterSaint Joseph, MO, CCN 264007 Hospital 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Jan 1, 1966
Jan 1, 1966
Hawthorn Children's Psychiatric HospitalSaint Louis, MO, CCN 264028 Hospital 5% Or Greater Direct Ownership Interest (100%) Jul 1, 1981

Owned or controlled facilities with NPI records 6

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

  • State of Missouri

    dba Hawthorn Children's Psychiatric Hosptial

    • Psychiatric Hospital
    • Saint Louis, MO
    • NPI 1033289897

    5% Or Greater Direct Ownership Interest

    CMS ownership
  • State of Missouri

    dba Fulton State Hospital

    • Psychiatric Hospital
    • Fulton, MO
    • NPI 1104878792

    5% Or Greater Direct Ownership Interest

    CMS ownership
  • State of Missouri

    dba Northwest MO Psychiatric Rehabilitation Center

    • Psychiatric Hospital
    • Saint Joseph, MO
    • NPI 1104879444

    5% Or Greater Direct Ownership Interest, Operational/Managerial Control

    CMS ownership
  • State of Missouri

    dba St Louis Forensic Treatment Center

    • Psychiatric Hospital
    • Saint Louis, MO
    • NPI 1578518239

    5% Or Greater Direct Ownership Interest

    CMS ownership
  • State of Missouri

    dba Center for Behavioral Medicine

    • Psychiatric Hospital
    • Kansas City, MO
    • NPI 1730134495

    5% Or Greater Direct Ownership Interest

    CMS ownership
  • State of Missouri

    dba Southeast MO Mental Health Center

    • Psychiatric Hospital
    • Farmington, MO
    • NPI 1861447526

    5% Or Greater Direct Ownership Interest

    CMS ownership

Practitioners & affiliated clinicians

Practitioners 24

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 24

NPI Registry JSON

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

{
    "created_epoch": "1148947200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1599091200000",
    "number": "1437106705",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1706 E ELM ST",
            "city": "JEFFERSON CITY",
            "state": "MO",
            "postal_code": "651014130",
            "telephone_number": "573-751-3398",
            "fax_number": "573-526-4560"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1010 W COLUMBIA ST",
            "city": "FARMINGTON",
            "state": "MO",
            "postal_code": "636402902",
            "telephone_number": "573-218-6792",
            "fax_number": "573-218-6703"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "STATE OF MISSOURI",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "STATE OF MISSOURI",
        "enumeration_date": "2006-05-30",
        "last_updated": "2020-09-03",
        "certification_date": "2020-09-03",
        "status": "A",
        "authorized_official_last_name": "BOECKMANN",
        "authorized_official_first_name": "MOLLY",
        "authorized_official_middle_name": "JANE",
        "authorized_official_title_or_position": "DIRECTOR ADMINISTRATIVE SERVICES",
        "authorized_official_telephone_number": "573-751-4055"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "208D00000X",
            "taxonomy_group": "",
            "desc": "General Practice",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "500490206",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Southeast MO Mental Health Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Southeast MO Mental Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Farmington, MO

Sources for this page

Verify at the official NPI Registry.