=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740441740
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CRITTENTON CHILDRENS CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2008
-----------------------------------------------------
Last Update Date | 06/23/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10918 ELM AVE
-----------------------------------------------------
City | KANSAS CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64134-4108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-767-4117
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10918 ELM AVE
-----------------------------------------------------
City | KANSAS CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64134-4108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THERAPIST
-----------------------------------------------------
Name | KIMBERLY LUDWIG
-----------------------------------------------------
Credential | LCSW LSCSW
-----------------------------------------------------
Telephone | 816-767-4117
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number | 2000148145
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------