Basic Information
| Provider Information | |||||||||
| NPI: | 1245390251 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COTTON O'NEIL CLINIC RECOVABLE TRUST | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COTTON O'NEIL BEHAVIORAL HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 SW GARFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | TOPEKA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 666061670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7853549591 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3707 SW 6TH AVE | ||||||||
| Address2: | |||||||||
| City: | TOPEKA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 666062084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7852704600 | ||||||||
| FaxNumber: | 7852704601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2006 | ||||||||
| LastUpdateDate: | 03/30/2016 | ||||||||
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| AuthorizedOfficialLastName: | YOCUM | ||||||||
| AuthorizedOfficialFirstName: | DEBRA | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7853549591 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0802X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Psychiatry | 2084P0804X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 2084P0805X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry | 2084P0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 110661 | 01 | KS | PTAN | OTHER | 100217350D | 05 | KS | MEDICAID |