1780965509 NPI number — FAMILY THERAPY OF THE OZARKS, INC

Table of content: (NPI 1780965509)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780965509 NPI number — FAMILY THERAPY OF THE OZARKS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY THERAPY OF THE OZARKS, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780965509
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/30/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1310 E KINGSLEY ST
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65804-7216
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-882-7700
Provider Business Mailing Address Fax Number:
417-885-3956

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1310 E. KINGSLEY
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65804-7238
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-882-7700
Provider Business Practice Location Address Fax Number:
417-885-3956
Provider Enumeration Date:
09/07/2011

Additional Information

Authorized Official

Authorized Official Last Name:
BOLING
Authorized Official First Name:
CATHERINE
Authorized Official Middle Name:
LEA
Authorized Official Title or Position:
CO-OWNER/THERAPIST
Authorized Official Telephone Number:
417-882-7700

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1780965509 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1346412327 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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