Basic Information
| Provider Information | |||||||||
| NPI: | 1265439871 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EMBERHOPE, INC | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| OtherOrganizationName: | EMBERHOPE, INC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4505 E 47TH ST S | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672101651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3165299100 | ||||||||
| FaxNumber: | 3165299351 | ||||||||
| Practice Location | |||||||||
| Address1: | 4505 E 47TH ST S | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672101651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3165299100 | ||||||||
| FaxNumber: | 3165299351 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2005 | ||||||||
| LastUpdateDate: | 07/01/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BULLA | ||||||||
| AuthorizedOfficialFirstName: | TOYIA | ||||||||
| AuthorizedOfficialMiddleName: | ANNE | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3165299389 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CPA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 2084N0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 251B00000X | 0015391-001 | KS | N | Agencies | Case Management | 251B00000X | 0003255-002 | KS | N | Agencies | Case Management | 251K00000X | KS | N | Agencies | Public Health or Welfare | 251V00000X | KS | N | Agencies | Voluntary or Charitable | 251S00000X | KS | Y | Agencies | Community/Behavioral Health |
No ID Information.