MEDICARE: PRAIRIE RIDGE INTEGRATED BEHAVIORAL HEALTHCARE

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	1201	IA
2	103TA0400X	Addiction (Substance Use Disorder) Psychologist	1201	IA
3	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	1201	IA
4	324500000X	Substance Abuse Rehabilitation Facility	1201	IA

General Provider Information

NPI Number	:	1952443632
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRAIRIE RIDGE INTEGRATED BEHAVIORAL HEALTHCARE

Provider Business Mailing Address
First Line	:	PO BOX 1338
Second Line	:
City	:	MASON CITY
State	:	IA
Zip	:	50402-1338
Country	:	US
Telephone Number	:	641-424-2391
Fax Number	:

Provider Business Practice Location Address
First Line	:	320 N EISENHOWER AVE
Second Line	:
City	:	MASON CITY
State	:	IA
Zip	:	50401-1521
Country	:	US
Telephone Number	:	641-424-2391
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. JAY HANSEN
Credential	:
Telephone Number	:	641-424-2391

Provider Enumeration Date	:	02/12/2007
Last Update Date	:	08/25/2017

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