Healthcare Provider Details

I. General information

NPI: 1184771149
Provider Name (Legal Business Name): MARK TWAIN ASSOCIATION FOR MENTAL HEALTH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 01/05/2021
Certification Date: 01/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

154 FORREST DR
HANNIBAL MO
63401-5511
US

IV. Provider business mailing address

154 FORREST DR
HANNIBAL MO
63401-5511
US

V. Phone/Fax

Practice location:
  • Phone: 573-221-2120
  • Fax: 573-221-4380
Mailing address:
  • Phone: 573-221-2120
  • Fax: 573-221-4380

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: MR. MICHAEL GENE CANTRELL
Title or Position: PRESIDENT & CEO
Credential: MBA
Phone: 573-600-9613