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General NPI Number Information
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NPI Number | 1063282390
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Entity Type | Organization
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Legal Business Name | MENTAL HEALTH SPECIALTY GROUP KS, P.A.
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Dates
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Enumeration Date | 01/08/2024
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Last Update Date | 09/12/2024
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Provider Practice Location Address
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Address Line | 801 E DOUGLAS AVE
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City | WICHITA
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State | KS
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Zip | 67202-3548
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Country | US
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Telephone | 323-205-7088
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 745249
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City | ATLANTA
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State | GA
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Zip | 30374-5249
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Country | US
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Telephone | 323-205-7088
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Fax |
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Authorized Official
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Title or Position | AUTHORIZED AGENT
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Name | GABRIEL DIOP
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Credential |
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Telephone | 323-205-7088
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084A0401X
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Taxonomy Name | Addiction Medicine (Psychiatry & Neurology) Physician
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License Number |
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License Number State |
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