1265103220 NPI number — MIDWEST BEHAVIORAL HEALTH LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265103220 NPI number — MIDWEST BEHAVIORAL HEALTH LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIDWEST BEHAVIORAL HEALTH LLC
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:
1265103220
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/30/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
102 N WILSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JEFFERSON
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50129-2126
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-386-2433
Provider Business Mailing Address Fax Number:
515-386-2124

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
102 N WILSON STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JEFFERSON
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50129
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-386-2433
Provider Business Practice Location Address Fax Number:
515-386-2124
Provider Enumeration Date:
09/21/2021

Additional Information

Authorized Official

Authorized Official Last Name:
BALL
Authorized Official First Name:
MEGAN
Authorized Official Middle Name:
RALYNN
Authorized Official Title or Position:
PROGRAM DIRECTOR, COUNSELOR
Authorized Official Telephone Number:
515-724-9896

Provider Taxonomy Codes

  • Taxonomy code: 324500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1444 . This is a "IOWA DEPARTMENT OF PUBLIC HEALTH" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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