Healthcare Provider Details

I. General information

NPI: 1982887105
Provider Name (Legal Business Name): INDIVIDUALIZED BEHAVIOR SOLUTIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2007
Last Update Date: 02/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6675 NW MEYERS CIR
PARKVILLE MO
64152-5220
US

IV. Provider business mailing address

PO BOX 901863
KANSAS CITY MO
64190-1863
US

V. Phone/Fax

Practice location:
  • Phone: 913-522-4775
  • Fax:
Mailing address:
  • Phone: 913-522-4775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number2010042683
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: LISA M. MILLER
Title or Position: CEO
Credential:
Phone: 913-522-4775