Healthcare Provider Details

I. General information

NPI: 1881432649
Provider Name (Legal Business Name): MID IOWA BEHAVIORAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2024
Last Update Date: 07/16/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 37TH ST STE 4
WEST DES MOINES IA
50266-1900
US

IV. Provider business mailing address

1300 37TH ST STE 4
WEST DES MOINES IA
50266-1900
US

V. Phone/Fax

Practice location:
  • Phone: 515-571-7953
  • Fax: 515-868-0306
Mailing address:
  • Phone: 515-571-7953
  • Fax: 515-868-0306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERT E. THACKER
Title or Position: OWNER/EXECUTIVE DIRECTOR
Credential: MA, IAADC, SAP
Phone: 515-571-7953