Healthcare Provider Details

I. General information

NPI: 1114189180
Provider Name (Legal Business Name): FAMILY INSTITUTE OF MENTAL HEALTH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2008
Last Update Date: 06/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

281 S JEFFERSON AVE SUITE J
LEBANON MO
65536-3226
US

IV. Provider business mailing address

23175 PARADISE DR
LEBANON MO
65536-5146
US

V. Phone/Fax

Practice location:
  • Phone: 417-588-2933
  • Fax:
Mailing address:
  • Phone: 417-588-2933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number000080
License Number StateMO

VIII. Authorized Official

Name: MS. BETSY HACKER WAHL
Title or Position: PRESIDENT/THERAPIST
Credential: L.P.C.
Phone: 417-588-2933