MEDICARE: MINERAL AREA PSYCHIATRIC SERVICES LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	261QP2300X	Primary Care Clinic/Center
2	208D00000X	General Practice Physician
3	2084P0800X	Psychiatry Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306379482
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINERAL AREA PSYCHIATRIC SERVICES LLC

Provider Business Mailing Address
First Line	:	203 S WASHINGTON ST
Second Line	:
City	:	FARMINGTON
State	:	MO
Zip	:	63640-1836
Country	:	US
Telephone Number	:	573-664-1047
Fax Number	:

Provider Business Practice Location Address
First Line	:	203 S WASHINGTON ST
Second Line	:
City	:	FARMINGTON
State	:	MO
Zip	:	63640-1836
Country	:	US
Telephone Number	:	573-664-1047
Fax Number	:

Authorized Official
Title or Position	:	PMHNP
Name	:	MR. GABRIEL E CRAWFORD
Credential	:	PMHNP-BC
Telephone Number	:	573-330-6468

Provider Enumeration Date	:	04/06/2017
Last Update Date	:	12/29/2024

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