Healthcare Provider Details

I. General information

NPI: 1952443632
Provider Name (Legal Business Name): PRAIRIE RIDGE INTEGRATED BEHAVIORAL HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 08/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 N EISENHOWER AVE
MASON CITY IA
50401-1521
US

IV. Provider business mailing address

PO BOX 1338
MASON CITY IA
50402-1338
US

V. Phone/Fax

Practice location:
  • Phone: 641-424-2391
  • Fax:
Mailing address:
  • Phone: 641-424-2391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number1201
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number1201
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1201
License Number StateIA
# 4
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number1201
License Number StateIA

VIII. Authorized Official

Name: MR. JAY HANSEN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 641-424-2391