Healthcare Provider Details

I. General information

NPI: 1295801678
Provider Name (Legal Business Name): BOYS & GIRLS TOWN OF MISSOURI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 W LOMBARD ST
SPRINGFIELD MO
65806-2720
US

IV. Provider business mailing address

426 N ALEXANDER AVE
REPUBLIC MO
65738-1235
US

V. Phone/Fax

Practice location:
  • Phone: 417-865-1646
  • Fax:
Mailing address:
  • Phone: 417-732-2416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number002691
License Number StateMO

VIII. Authorized Official

Name: MS. MARLA H. UNDERWOOD
Title or Position: THERAPIST
Credential: MS, LPC, NCC
Phone: 417-865-1646