Voluntary Withdrawal from TRICARE Certification. TRICARE Certification Expired. Recent Certification Date Corrected to 6/30/2009

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1 June 10, 2013 To Whom It ay Concern: Attached is the TRICARE ental Health Certification List as of June 10, 2013 of reestanding Psychiatric Partial Hospitalization s (PHPs), Residential Treatment Centers (RTCs) and reestanding Substance Use Disorder Rehabilitation acilities (SUDRs). The following table lists status changes, which occurred ay 1-31, 2013: Name / Dba Change Eastern Idaho Regional edical Center - Behavioral Health Center Eastern Idaho Health Services, Inc East 25th Street Idaho alls, ID Phone: (208) EIN: Effective RTC ID 5/30/2013 LaAmistad Behavioral Health Services d/b/a Central lorida Behavioral Health 6601 Central lorida Parkway Orlando, L Phone: EIN: Addiction Recovery Resources, Inc. Addiction Recovery Resources, Inc Wabash etairie, LA Phone: (504) EIN: Lakeland Regional Hospital Lakeland Hospital Acquisition Corporation 440 South arket Avenue Springfield, O Phone: (417) EIN: Voluntary Withdrawal from TRICARE Certification TRICARE Certification Expired Recent Corrected to 6/30/2009 RTC L 05/16/2013 SUDR LA 05/13/2013 RTC O 5/29/2013 Sincerely, KePRO/TRICARE 777 East Park Drive, Harrisburg, PA TRICARE HOTLINE: , AX ,

2 onthly ental Health Listing Report As of ay 30, 2013

3 TABLE O CONTENTS LISTING O ENTAL HEALTH ACILITIES CERTIIED BY TRICARE Alabama. 1 Alaska.. 2 Arizona.. 3 Arkansas... 3 California.. 4 Colorado Connecticut lorida. 6 Georgia Hawaii Indiana Kansas. Kentucky... aryland issouri. 13 ontana 15 Nevada New exico North Carolina Ohio.. 18 Pennsylvania 18 South Carolina Tennessee. 20 Texas. 21 Utah 25 Virginia. 26 Washington. 30 Appendix A Glossary of Acronyms and Terms A1

4 Information ALABAA AL SUDR Bradford Health Services - Huntsville 555 Sparkman Drive, Suite 208 Huntsville, AL Phone: (256) EIN: Adult Evening Sub Use Half Day Evening Use Half Day Adult id Day onday- Thursday onday - Thursday onday - Thursday 10 10/07/ /07/ /07/ /27/ /27/ /27/2009 Adult orning onday- Thursday 10/07/ /27/2009 AL SUDR Bradford Health Services - Huntsville Lodge 1600 Browns erry Road adison, AL Phone: (256) EIN: /Adult Inpatient Rehab Age Adult Inpatient Rehab/Detox /29/ /29/ /16/ /16/2009 Adult Sub Use ull Day onday - Sunday 11/29/ /16/2009 Sub Use ull Day onday - Sunday 11/29/ /16/2009 Page 1

5 Information ALABAA AL SUDR Bradford Health Services - Warrior Lodge 1189 Allbritton Road Warrior, AL Phone: (205) EIN: Adult Detox Adult Inpatient Rehabilitation Adult Sub Use ull Day onday- riday /04/ /04/ /04/ /07/ /07/ /07/2009 ALASKA AK RTC DeBarr Residential Treatment Center rontline Hospital, LLC 1500 DeBarr Circle Anchorage, AK Phone: (907) EIN: (Age 6-18) 60 07/16/ /28/2009 Page 2

6 Information ARIZONA AZ RTC Southwest Children s Health Services dba Parc Place 2190 North Grace Boulevard Chandler, AZ Phone: EIN #: (Age 11-15) (Age 15-17) (Age 11-17) /17/20 01/17/20 01/17/20 01/17/20 01/17/20 01/17/20 (Age 11-17) 26 01/17/20 01/17/20 ARKANSAS AR RTC BHC Pinnacle Pointe Hospital inancial Center Parkway Little Rock, AR Phone: (501) EIN: CITC - ale-emale Age 5- AITC - ale Age /22/ /22/ /26/20 08/26/20 AITC - emale Age /26/20 Page 3

7 Information CALIORNIA CA SUDR Lasting Recovery arkas & Saalinger Psychological Corp 6046 Cornerstone Ct W. #13 San Diego, CA 921 Phone: (858) EIN: Adult Sub Use ull Day onday-riday 32 05/07/ /07/2010 COLORADO CO RTC CBR Youth Connect CBR Youth Connect Hwy 109 La Junta, CO Phone: (719) EIN: Age /20/ /16/2009 Page 4

8 Information COLORADO CO RTC Cedar Springs Behavioral Health Systems, Inc. PSI Cedar Springs Hospital, Inc Southgate Road Colorado Springs, CO Phone: (719) EIN: ountain View Place - Child Age 5- ountain View Place - Age /19/ /19/1990 8/07/20 08/07/20 Connections Reactive Attachment Unit Age /07/20 08/07/20 CONNECTICUT CT SUDR Stonington Institute Stonington Behavioral Health, Inc. 75 Swanton Hill Road North Stonington, CT Phone: (860) EIN: Adult ull Day Adult Inpatient Rehabilitation Detox/Inpt. Rehab onday-riday /28/ /28/ /28/ /24/ /24/ /23/2013 Page 5

9 Information LORIDA L RTC LaAmistad Behavioral Health Services LaAmistad Behavioral Health Services 1650 Park Avenue North aitland, L Phone: (407) EIN: (Age -18) Child (Age 5-11) & /23/1999 7/5/2011 L RTC anatee Palms Youth Services Premier Behavioral Solutions of lorida, Inc st Street West Bradenton, L Phone: (941) EIN: Ages Ages Child Ages /29/2009 7/19/2010 L RTC National Deaf Academy U.S. Highway 441 t. Dora, L Phone: (352) EIN: Child/ Bldg Ages Adult Building 7 Ages /13/2011 9/13/2011 Page 6

10 Information LORIDA L SUDR The riary The riary of Lakeview 4400 Hickory Shores Blvd Gulf Breeze, L Phone: (850) EIN: Adult Detox Adult Inpatient Rehabilitation Adult Sub Use Partial-ull Day onday- Saturday /17/1993 2/16/2011 L SUDR Twelve Oaks Alcohol & Drug Treatment Center Bowling Green Inn of Pensacola 2068 Healthcare Avenue Navarre, L Phone: (850) EIN: Adult Detox/Rehab Adult Sub Use ull Day Sub Use ull Day onday- Sunday onday- Sunday /19/ /19/ /19/ /01/20 11/01/20 11/01/20 L RTC University Behavioral, LLC d/b/a University Behavioral Center 2500 Discovery Drive Orlando, L Phone: EIN: Ages 6-17 Ages 6-17 emale emale /3/20 4/3/20 Page 7

11 Information GEORGIA GA SUDR Bradford Health Services - Augusta 105 Rossmore Place Augusta, GA Phone: (706) EIN: /Adult Sub Use Half Day Adult Evening Sub Use Half Day onday- Thursday, Saturday onday- Thursday 8 10/05/ /05/ /23/ /23/2011 GA SUDR Bradford Health Services - Columbus 860 Brookstone Center Parkway Suite A Columbus, GA Phone: (706) EIN: Adult Evening Sub Use Half Day Evening Sub Use Half Day onday- Thursday onday - Thursday 18 8 /27/2007 /27/ /10/ /10/2011 GA RTC Coastal Harbor Treatment Center UHS of Savannah, LLC 1150 Cornell Avenue Savannah, GA Phone: (9) EIN: One East Age One North Age 9-13 emale ale /18/2008 2/15/20 Page 8

12 Information GEORGIA GA RTC Laurel Heights UHS Laurel Heights L.P. 934 Briarcliff Road NE Atlanta, GA Phone: (404) EIN: /14/ /14/2010 GA RTC Ramsey Youth Services of Georgia, Inc., d/b/a acon Behavioral Health System 3500 Riverside Drive acon, GA 310 Phone: (478) EIN: Child & 3rd loor Ages: /15/20 11/15/20 GA SUDR Recovery Place, Inc. Recovery Place, Inc. 835 East 65th Street Savannah, GA Phone: (9) EIN: Adult ull Day Adult Half Day onday-riday onday-riday /05/ /05/ /19/ /19/2010 Page 9

13 Information GEORGIA GA PHP Talbott Columbus 00 Brookstone Centre Parkway Suite 210 Columbus, GA Phone: (706) EIN: Adult Substance Use Partial - ull Day Adult Substance Use Partial - Half Day onday-riday onday-riday 02/02/20 02/02/20 02/02/20 02/02/20 GA RTC Youth Villages Youth Villages, Inc Dorsett Shoals Road Douglasville, GA Phone: (901) EIN: /30/ /29/20 HAWAII HI RTC Kahi ohala Behavioral Health Sutter Health Pacific ort Weaver Road Ewa Beach, HI Phone: (808) EIN: Child & /16/ /06/2011 Page 10

14 Information HAWAII HI RTC The Queen s edical Center/ amily Treatment Center The Queen's edical Center 1301 Punchbowl Honolulu, HI Phone: (808) EIN: Unit East Child /08/ /08/ /22/ /22/2010 IDAHO ID RTC Eastern Idaho Regional edical Center - Behavioral Health Center Eastern Idaho Health Services, Inc East 25th Street Idaho alls, ID Phone: (208) EIN: RTC 22 10/19/2009 1/14/2013 Page 11

15 Information INDIANA IN RTC ichiana Behavioral Health Center HHC Indiana, Inc North Oak Road Plymouth, IN Phone: (574) EIN: Child/ 29 08/16/ /09/2009 IN RTC Valle Vista Health System Valle Vista Hospital, LLC. 898 East ain Street Greenwood, IN Phone: (317) EIN: Ages -18 Ages /16/ /16/ /16/ /16/2013 KANSAS KS RTC KVC Hospitals, Inc. Prarie Ridge Psychiatric Hospital 4300 Brenner Drive Kansas City, KS Phone: EIN: Ages /14/20 3/14/20 Page

16 Information KENTUCKY KY RTC The Brook Hospitals - Dupont TBD Acquisition, LLC Browns Lane Louisville, KY Phone: (502) EIN: Child Ages /02/ //2011 KY RTC The Brook Hospitals - KI KI Acquisition 8521 LaGrange Road Louisville, KY Phone: (502) EIN: Ages Ages /8/ /08/ // //2011 KY RTC Spring eadows Center d/b/a Spring eadows 330 Hope Street ount Washington, KY Phone: (502) EIN: Ages // //2013 Page 13

17 Information ARYLAND D RTC Adventist Healthcare, Inc Adventist Behavioral Health Broschart Road Rockville, D Phone: (301) EIN: Ages /2 Ages / /06/ /06/ /06/ /06/2011 ISSOURI O RTC Crittenton Children s Center Crittenton Center Elm Avenue Kansas City, O Phone: (816) EIN: Ages /08/ /14/2010 O RTC Heartland Behavioral Health Services, Inc. Great Plains Hospital, Inc West Ashland Nevada, O Phone: (417) EIN: Specialized Boys/Girls 36 08/15/ /11/2010 Page 14

18 Information ISSOURI O RTC Lakeland Regional Hospital Lakeland Hospital Acquisition Corporation 440 South arket Avenue Springfield, O Phone: (417) EIN: Northeast Girls RTC 2 North Boys RTC 18 10/8/2007 6/30/2009 ONTANA T RTC Shodair Children s Hospital ontana Children's Home & Hospital 2755 Colonial Drive Helena, T Phone: (406) EIN: Child /25/2003 5//2009 T RTC ACADIA ONTANA 55 Basin Creek Road Butte, T Phone: EIN: Child Ages /24/20 5/24/20 Page 15

19 Information NEVEDA NV RTC Willow Springs Center Willow Springs, LLC 690 Edison Way Reno, NV Phone: (775) EIN: Child /08/ /08/ /08/ /16/ /16/ /16/2010 NEW EXICO N RTC esilla Valley Hospital BHC esilla Valley Hospital, LLC 3751 Del Rey Boulevard Las Cruces, N 880 Phone: (800) EIN: /05/ /05/ /09/ /09/2011 N RTC Desert Hills Youth and amily Centered Services of New exico, Inc., d/b/a Desert Hills 5310 Sequoia NW Albuquerque, N 870 Phone: (505) EIN: (ages 5-17) emale (Ages 5-17) 10/24/20 10/24/20 10/24/20 10/24/20 Page 16

20 Information NORTH CAROLINA NC PHP Healthcare Solutions Network of North Carolina 170 Old Naples Road Hendersonville, NC Phone: (828) EIN: Adult Half Day onday - riday 60 08/13/ /11/2010 NC RTC Brynn arr Hospital Brynn arr Hospital 192 Village Drive Jacksonville, NC Phone: (910) EIN: RTC 24 3/21/2007 8/24/2009 NC SUDR Wilmington Treatment Center Wilmington Treatment Center, Inc Troy Drive Wilmington, NC Phone: (910) EIN: Adult Inpatient Rehab/Detox Adult Sub Use ull Day (Ages 18-99) (Ages 18-99) onday- Sunday /05/ /05/2003 /14/20 /14/20 Page 17

21 Information OHIO OH RTC Belmont Pines Hospital Belmont Pines Hospital 615 Churchill-Hubbard Road Youngstown, OH Phone: (330) EIN: Child Ages 5-11 Ages /02/ /02/2009 PENNSYLVANIA PA RTC KidsPeace National Centers, Inc KidsPeace Drive Orefield, PA Phone: EIN: Ages & 24 4/5/20 4/5/20 SOUTH CAROLINA SC RTC Palmetto Lowcountry Behavioral Health 2777 Speissegger Drive Charleston, SC Phone: (843) EIN: RTC RTC /07/2004 /07/ /26/ /26/2010 Page 18

22 Information SOUTH CAROLINA SC RTC Palmetto Pines (Summerville) Behavioral Health 225 idland Parkway Summerville, SC Phone: EIN: Child/ RTC Ages: /9/20 8/9/20 SC RTC Three Rivers Residential Treatment - idlands Campus 200 Ermine Road West Columbia, SC Phone: (803) EIN: KEYS Unit Ages /2 KARS Child Unit Ages /26/2006 8// /5/ /5/2011 SC PHP Three Rivers Residential Treatment - idlands Campus 200 Ermine Road West Columbia, SC Phone: (803) EIN: Pathways Partial 1 pm to 7 pm ull Day 20 04/22/2013 4/22/2013 Page 19

23 Information SOUTH CAROLINA SC SUDR Earle E. orris Jr. Alcohol & Drug Addiction Treatment 610 aison Drive Columbia, SC Phone: (803) EIN: Adult Detox Adult Inpatient Rehabilitation Adult Inpatient Rehabilitation 24 04/27/ /27/ /27/ /03/ /03/ /03/2009 Dual Diagnosis Inpatient Rehab/Detox 04/27/ /03/2009 TENNESSEE TN RTC Compass Intervention Center Keystone emphis, LLC 7900 Lowrance Road emphis, TN 385 Phone: (901) EIN: Child /10/ /10/ /13/ /13/2009 Page 20

24 Information TENNESSEE TN SUDR Bradford Health Services - Clarksville 235 A Dunbar Cave Road Clarksville, TN Phone: (931) EIN: Adult Evening Sub Use Half Day Adult ull Day Adult ull Day All s: onday- Thursday, Saturday /30/2003 1/23/2009 Evening Sub Use Half Day 10 TEXAS TX RTC Cedar Crest Hospital and RTC HTH Cedar Crest, LLC 3500 South IOH-35 Belton, TX Phone: (254) EIN: Ages /01/ /31/2010 Page 21

25 Information TEXAS TX RTC Laurel Ridge Treatment Center Texas Laurel Ridge Hospital Corporate Woods Drive San Antonio, TX Phone: (800) EIN: Child /01/ /01/ /30/ /30/2011 TX RTC eridell Achievement Center 550 West Hwy 29 Liberty Hill, TX Phone: (800) EIN: RTC & /10/ /10/ /10/ /10/ /10/ /18/ /18/ /18/ /18/ /18/2009 TX RTC San arcos Treatment Center 0 Bert Brown Road San arcos, TX Phone: (615) EIN: Child/ Child/ Child/ /01/ /01/ /01/ /01/ /01/ /01/2010 Child/ 15 01/01/ /01/2010 Page 22

26 Information TEXAS TX RTC Southwest ental Health Center 8535 Tom Slick Drive San Antonio, TX Phone: (210) EIN: Child/ 52 02/22/1983 /05/2008 TX PHP El Paso Psychiatric Assoc. PA Alternative Centre 7760 Alabama Street El Paso, TX Phone: (915) EIN: Adult Sub Use ull Day Adult Sub Use Half Day Sub Use Half Day onday - riday onday - riday onday - riday /03/ /03/ /03/ /03/ /03/ /03/2011 TX SUDR Red River Recovery Center Red River Recovery, LLC 2501 Taylor Street Wichita alls, TX Phone: (940) EIN: Adult Sub Use ull Day 7 days 18 02/05/ /17/2010 Page 23

27 Information TEXAS TX SUDR Starlite Recovery Center 230 esa Verde Drive - East P.O. Box 317 Center Point, TX Phone: (830) EIN: Adult Detoxification Unit Adult Inpatient Rehabilitation ull Day /17/ /17/ /17/ /17/ /17/ /17/2011 Adult Substance Use Partial Hospitalization Inpatient Rehabilitation ull Day /17/ /17/ /17/ /17/2011 Substance Use PHP Page 24

28 Information UTAH UT RTC Center for Change UHS of Timpanogos 1790 North Street Orem, UT Phone: (801) EIN: RTC 24 /24/2010 /24/2010 UT RTC Provo Canyon School UHS of Provo Canyon, Inc North University Avenue Provo, UT Phone: (801) EIN: Intensive Diagnostic & Stabilization Unit (Ages 13-18) ale 08/11/ /11/2010 UT RTC Provo Canyon School UHS of Provo Canyon, Inc East 750 North Orem, UT Phone: (801) EIN: RTC 48 02/09/ /09/2011 Page 25

29 Information VIRGINIA VA RTC Keystone Newport News, LLC Warwick Boulevard Newport News, VA Phone: (757) EIN: Ages /09/ /13/20 VA RTC Harbor Point Behavioral Health Center 301 ort Lane Portsmouth, VA Phone: EIN: Ages Ages /07/20 05/07/20 /07/20 /07/20 Gen Psych Ages /07/20 /07/20 Child RTC Unit Ages 6-24 /07/20 /07/20 VA RTC Poplar West HHC Poplar Springs, Inc. 350 Poplar Drive Petersburg, VA Phone: (804) EIN: Ages Ages Page /24/1993 6/18/2010

30 Information VIRGINIA VA RTC Riverside Behavioral Health Center 2244 Executive Drive Hampton, VA Phone: (757) EIN: Ages Ages /8/ /08/ /25/20 07/25/20 VA RTC The Kempsville Center for Behavioral Health 860 Kempsville Road Norfolk, VA Phone: (757) EIN: (Ages 11-17) (Ages 11-17) emale ale 22 11/27/ /27/ /06/20 03/06/20 VA RTC Hallmark Youthcare - Richmond 800 West Creek Parkway Richmond, VA Phone: (804) EIN: Boys RTC 42 03/03/ /03/2011 Page 27

31 Information VIRGINIA VA SUDR Life Center of Galax 1 Painter Street Galax, VA Phone: (276) EIN: Adult Detox/Rehab Adult ull Day onday- Sunday /25/ /25/ /25/ /25/2010 VA RTC North Spring Behavioral Healthcare Victory Lane Leesburg, VA Phone: EIN: (Ages 13-17) 16 3/8/20 3/8/20 VA RTC Cumberland Hospital for Children and s 9407 Cumberland Road New Kent, VA 234 Phone: (804) EIN: Ages Ages /27/ /27/2011 Page 28

32 Information VIRGINIA VA SUDR Williamsburg Place/The arley Center Diamond Healthcare of Williamsburg Inc oorestown Road Williamsburg, VA Phone: (757) EIN: Adult Detox Adult Inpatient Rehabilitation Adult Sub Use ull Day Adult Sub Use ull Day onday - riday Sunday - Saturday /13/ /13/ /13/ /13/ /13/ /13/ /13/ /13/2011 VA RTC The Barry Robinson Center 443 Kempsville Road Norfolk, VA Phone: (757) EIN: Children's RTC (Ages 6-13) 24 1/24/2013 1/24/2013 Page 29

33 Information WASHINGTON WA RTC Tamarack Center 2901 West ort George Wright Drive Spokane, WA Phone: (509) EIN: /22/1995 /24/2010 Page 30

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