Healthcare Provider Details

I. General information

NPI: 1417332230
Provider Name (Legal Business Name): NEW LEAF THERAPY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2015
Last Update Date: 07/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1204 SE LOUIS DR
MULVANE KS
67110-1113
US

IV. Provider business mailing address

1204 SE LOUIS DR
MULVANE KS
67110-1113
US

V. Phone/Fax

Practice location:
  • Phone: 316-351-8696
  • Fax: 844-581-0869
Mailing address:
  • Phone: 316-351-8696
  • Fax: 844-581-0869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1982
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number812
License Number StateKS

VIII. Authorized Official

Name: SUSAN DUTCHER
Title or Position: OWNER
Credential: PSYD, LP, LCMFT
Phone: 316-351-8696