Provider Demographics
NPI:1447640164
Name:SOUTHEASTERN BEHAVIORAL ASSOCIATES, LLC
Entity type:Organization
Organization Name:SOUTHEASTERN BEHAVIORAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:STEPHENSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:575-714-3410
Mailing Address - Street 1:518 E 18TH ST # B
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-9268
Mailing Address - Country:US
Mailing Address - Phone:575-714-3410
Mailing Address - Fax:
Practice Address - Street 1:518 E 18TH ST # B
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-9268
Practice Address - Country:US
Practice Address - Phone:575-714-3410
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-02
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-07223101YP2500X
NM0129911101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty