=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487650842
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HERITAGE MENTAL HEALTH CLINIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2005
-----------------------------------------------------
Last Update Date | 06/24/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2110 SW BELLE AVE STE B
-----------------------------------------------------
City | TOPEKA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66614-1773
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 785-272-5566
-----------------------------------------------------
Fax | 785-272-5967
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2110 SW BELLE AVE STE B
-----------------------------------------------------
City | TOPEKA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66614-1773
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 785-272-5566
-----------------------------------------------------
Fax | 785-272-5967
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING MANAGER
-----------------------------------------------------
Name | DORA CLARK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 785-272-5566
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 1366
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 04-20537
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 311
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------