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General NPI Number Information
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NPI Number | 1407626039
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Entity Type | Organization
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Legal Business Name | TREE OF LIFE CARE LLC
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Dates
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Enumeration Date | 01/04/2024
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Last Update Date | 06/20/2024
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Provider Practice Location Address
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Address Line | 815 N WACO AVE STE 35
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City | WICHITA
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State | KS
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Zip | 67203-3928
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Country | US
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Telephone | 316-290-9046
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Fax |
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Provider Business Mailing Address
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Address Line | 620 N ROCK RD STE 230-122
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City | DERBY
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State | KS
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Zip | 67037-3681
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Country | US
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Telephone | 316-207-2545
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Fax |
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Authorized Official
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Title or Position | MENTAL HEALTH PROVIDER
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Name | DAVON ANDERSON
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Credential | LMSW
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Telephone | 316-207-2545
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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