MEDICARE: OTHMER PSYCHIATRIC CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	1473	MO
2	1041C0700X	Clinical Social Worker	003750	MO
3	2084P0800X	Psychiatry Physician	2005021811	MO
4	364S00000X	Clinical Nurse Specialist	2005027490	MO
5	2084P0800X	Psychiatry Physician	33862	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2005021811	OTHER	MO	STATE OF MO MD LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MD-063-511L	OTHER	MO	CHILD AND ADOLESCENT PSYC

General Provider Information

NPI Number	:	1134310154
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OTHMER PSYCHIATRIC CENTER

Provider Business Mailing Address
First Line	:	5709 NW 64TH TER
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64151-2382
Country	:	US
Telephone Number	:	816-746-5555
Fax Number	:	816-746-5996

Provider Business Practice Location Address
First Line	:	5709 NW 64TH TER
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64151-2382
Country	:	US
Telephone Number	:	816-746-5555
Fax Number	:	816-746-5996

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. SIEGLINDE C OTHMER
Credential	:
Telephone Number	:	816-746-5555

Provider Enumeration Date	:	08/05/2007
Last Update Date	:	06/08/2010

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