=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083221303
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THRIVE RESTORATIVE SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2020
-----------------------------------------------------
Last Update Date | 10/01/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1911 NORTH 62ND STREET
-----------------------------------------------------
City | KANSAS CITY
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-303-7416
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12641 ANTIOCH RD STE 1089
-----------------------------------------------------
City | OVERLAND PARK
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66213-1701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-303-7416
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DELISSA COOPER
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 913-486-5152
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------