Healthcare Provider Details

I. General information

NPI: 1053431676
Provider Name (Legal Business Name): THE MIRROR, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 01/10/2022
Certification Date: 01/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 E 5TH ST
NEWTON KS
67114-2206
US

IV. Provider business mailing address

130 E 5TH ST
NEWTON KS
67114-2206
US

V. Phone/Fax

Practice location:
  • Phone: 316-283-6743
  • Fax: 316-283-6830
Mailing address:
  • Phone: 316-283-6743
  • Fax: 316-283-6830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number0093
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number0093
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number0093
License Number StateKS

VIII. Authorized Official

Name: ELIZABETH T MEITNER
Title or Position: DIRECTOR OF UTILIZATION
Credential:
Phone: 316-400-6863