Healthcare Provider Details

I. General information

NPI: 1093471443
Provider Name (Legal Business Name): REPACKED COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2021
Last Update Date: 11/10/2021
Certification Date: 11/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1412 S 16TH ST
LEAVENWORTH KS
66048-2915
US

IV. Provider business mailing address

1412 S 16TH ST
LEAVENWORTH KS
66048-2915
US

V. Phone/Fax

Practice location:
  • Phone: 913-388-9143
  • Fax:
Mailing address:
  • Phone: 913-388-9143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SUSAN MARIE KERR
Title or Position: OWNER/COUNSELOR
Credential: LPC-T
Phone: 913-388-9143