=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073943874
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KVC BEHAVIORAL HEALTHCARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2013
-----------------------------------------------------
Last Update Date | 11/15/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21350 W 153RD ST
-----------------------------------------------------
City | OLATHE
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66061-5413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-332-4900
-----------------------------------------------------
Fax | 913-780-1284
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21350 W 153RD ST
-----------------------------------------------------
City | OLATHE
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66061-5413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-332-4900
-----------------------------------------------------
Fax | 913-780-1284
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIVERSION SPECIALIST
-----------------------------------------------------
Name | KRYSTAL MARIE SHARP
-----------------------------------------------------
Credential | MA LPA
-----------------------------------------------------
Telephone | 859-254-1035
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 2013-07
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------