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General NPI Number Information
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NPI Number | 1235410697
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Entity Type | Organization
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Legal Business Name | OTTUMWA MENTAL WELLNESS CENTER
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Dates
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Enumeration Date | 08/30/2011
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Last Update Date | 07/05/2013
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Provider Practice Location Address
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Address Line | 801 N QUINCY AVE
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City | OTTUMWA
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State | IA
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Zip | 52501-3869
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Country | US
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Telephone | 641-684-7744
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Fax | 641-684-7700
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Provider Business Mailing Address
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Address Line | 801 N QUINCY AVE STE 4
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City | OTTUMWA
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State | IA
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Zip | 52501-3869
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Country | US
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Telephone | 641-684-7744
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Fax | 641-684-7700
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Authorized Official
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Title or Position | OWNER
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Name | MELISSA N GENTRY
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Credential | P.A-C
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Telephone | 641-684-7744
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State | IA
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