=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255724654
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MBSS COUNSELING GROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2015
-----------------------------------------------------
Last Update Date | 04/10/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5706 TROOST AVE
-----------------------------------------------------
City | KANSAS CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64110-2826
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-866-1192
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5510 NE ANTIOCH RD 265
-----------------------------------------------------
City | KANSAS CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64119-2301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-866-1192
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COUNSELOR
-----------------------------------------------------
Name | MR. JAHI BOSEDA
-----------------------------------------------------
Credential | CRADC
-----------------------------------------------------
Telephone | 816-679-2160
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3245S0500X
-----------------------------------------------------
Taxonomy Name | Children's Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number | NO.6748
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------