Healthcare Provider Details

I. General information

NPI: 1053711317
Provider Name (Legal Business Name): SUCCESSFUL EDGE, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2014
Last Update Date: 08/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6301 ROCKHILL RD
KANSAS CITY MO
64131-1124
US

IV. Provider business mailing address

6013 WOODLAND AVE
KANSAS CITY MO
64110-3555
US

V. Phone/Fax

Practice location:
  • Phone: 816-807-6605
  • Fax:
Mailing address:
  • Phone: 816-807-6605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number2012037387
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number2012037387
License Number StateMO

VIII. Authorized Official

Name: STANLEY ARNOLD ARCHIE
Title or Position: LICENSE PROFESSIONAL COUNSELOR
Credential: LPC
Phone: 816-807-6605