Healthcare Provider Details

I. General information

NPI: 1043580194
Provider Name (Legal Business Name): CROSSROADS BEHAVIORAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2012
Last Update Date: 05/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 DEER RUN RD.
OAK GROVE MO
64075
US

IV. Provider business mailing address

1611 DEER RUN RD
OAK GROVE MO
64075-5210
US

V. Phone/Fax

Practice location:
  • Phone: 816-838-1808
  • Fax:
Mailing address:
  • Phone: 816-838-1808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number120123210218441
License Number StateMO

VIII. Authorized Official

Name: JEREMIAH THOMAS HARTLEY
Title or Position: CEO
Credential: MA
Phone: 816-838-1808