Healthcare Provider Details

I. General information

NPI: 1306872064
Provider Name (Legal Business Name): FAMILY THERAPY INSTITUTE MIDWEST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 11/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2619 W. 6TH STREET, SUITE C
LAWRENCE KS
66049
US

IV. Provider business mailing address

2619 W. 6TH STREET, SUITE C
LAWRENCE KS
66049
US

V. Phone/Fax

Practice location:
  • Phone: 785-830-8299
  • Fax: 785-749-2581
Mailing address:
  • Phone: 785-830-8299
  • Fax: 785-749-2581

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number0894
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number1109
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6890
License Number StateKS
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1740
License Number StateKS
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3569
License Number StateKS
# 6
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number74564
License Number StateKS
# 7
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number46111
License Number StateKS

VIII. Authorized Official

Name: MARY LU EGIDY
Title or Position: OWNER
Credential: APRN
Phone: 785-830-8299