Healthcare Provider Details

I. General information

NPI: 1861311797
Provider Name (Legal Business Name): PROVIDENCE SUPPORT SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6204 NE NORMANDY DR
KANSAS CITY MO
64118-4826
US

IV. Provider business mailing address

312 SW GREENWICH DR
LEES SUMMIT MO
64082-4408
US

V. Phone/Fax

Practice location:
  • Phone: 913-404-9848
  • Fax: 913-884-1720
Mailing address:
  • Phone: 913-404-9848
  • Fax: 913-884-1720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: THERESIA MUSHI
Title or Position: MANAGING MEMBER
Credential: MSN, ARNP, PMHNP-BC
Phone: 913-404-9848