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General NPI Number Information
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NPI Number | 1902262991
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Entity Type | Organization
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Legal Business Name | FORTITUDE INTENSIVE OUTPATIENT PROGRAM LLC
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Dates
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Enumeration Date | 01/07/2016
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Last Update Date | 01/07/2016
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Provider Practice Location Address
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Address Line | 500 W MAIN ST ST. 204
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City | BRANSON
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State | MO
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Zip | 65616-2727
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Country | US
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Telephone | 417-243-7777
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Fax | 417-243-7778
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Provider Business Mailing Address
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Address Line | 500 W MAIN ST ST. 204
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City | BRANSON
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State | MO
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Zip | 65616-2727
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Country | US
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Telephone | 417-243-7777
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Fax | 417-243-7778
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Authorized Official
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Title or Position | MANAGER
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Name | MRS. SHABANA INSAF
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Credential | PHD
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Telephone | 417-243-7777
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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