1750615829 NPI number — NORTHLAND BEHAVIORAL HEALTH & WELLNESS, LLC

Table of content: (NPI 1750615829)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750615829 NPI number — NORTHLAND BEHAVIORAL HEALTH & WELLNESS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHLAND BEHAVIORAL HEALTH & WELLNESS, 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:
1750615829
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/23/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
119 NE 72ND ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLADSTONE
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64118-1826
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-420-3130
Provider Business Mailing Address Fax Number:
816-734-0083

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
119 NE 72ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLADSTONE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64118-1826
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-420-3130
Provider Business Practice Location Address Fax Number:
816-734-0083
Provider Enumeration Date:
09/23/2009

Additional Information

Authorized Official

Authorized Official Last Name:
SHOFFNER
Authorized Official First Name:
AMY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PSYCHOLOGIST
Authorized Official Telephone Number:
816-420-3130

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  2005004519 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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