Healthcare Provider Details

I. General information

NPI: 1104980267
Provider Name (Legal Business Name): EAST CENTRAL MISSOURI BEHAVIORAL HEALTH SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 09/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 KELLEY PKWY
MEXICO MO
65265-3811
US

IV. Provider business mailing address

340 KELLEY PKWY
MEXICO MO
65265-3811
US

V. Phone/Fax

Practice location:
  • Phone: 573-582-1234
  • Fax: 573-582-1212
Mailing address:
  • Phone: 573-582-1234
  • Fax: 573-582-1212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number5726-7685
License Number StateMO

VIII. Authorized Official

Name: TERRY MACKEY
Title or Position: CFO
Credential: LCSW
Phone: 573-582-1234