MEDICARE: DERBY EMOTIONAL WELLNESS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	1527	KS
2	163WP0808X	Psychiatric/Mental Health Registered Nurse	74173	KS
3	104100000X	Social Worker	4695	KS
4	104100000X	Social Worker	1527	KS

General Provider Information

NPI Number	:	1275777328
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DERBY EMOTIONAL WELLNESS

Provider Business Mailing Address
First Line	:	1721 E OSAGE
Second Line	:	SUITE 300
City	:	DERBY
State	:	KS
Zip	:	67037-2290
Country	:	US
Telephone Number	:	316-788-1907
Fax Number	:	316-788-1941

Provider Business Practice Location Address
First Line	:	1721 E OSAGE
Second Line	:	SUITE 300
City	:	DERBY
State	:	KS
Zip	:	67037-2290
Country	:	US
Telephone Number	:	316-788-1907
Fax Number	:	316-788-1941

Authorized Official
Title or Position	:	PHD, LSCSW
Name	:	ALICIA ANN MYERS-LANDSVERK
Credential	:	LSCSW
Telephone Number	:	316-788-1907

Provider Enumeration Date	:	04/20/2009
Last Update Date	:	06/04/2010

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Directions to “DERBY EMOTIONAL WELLNESS ” Practice Location

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