Basic Information
| Provider Information | |||||||||
| NPI: | 1063899813 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOOS | ||||||||
| FirstName: | CHRISTY | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2707 E. 21ST ST. NORTH | ||||||||
| Address2: | HEALTHCORE CLINIC | ||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 67214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166910241 | ||||||||
| FaxNumber: | 3166919875 | ||||||||
| Practice Location | |||||||||
| Address1: | 2707 E. 21ST ST. NORTH | ||||||||
| Address2: | HEALTHCORE CLINIC | ||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 67214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166910241 | ||||||||
| FaxNumber: | 3166919875 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2015 | ||||||||
| LastUpdateDate: | 04/30/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 9122 | KS | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 104100000X | 01 | KS | PROVIDER TAXONOMY CODE | OTHER |