Basic Information
| Provider Information | |||||||||
| NPI: | 1275661977 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BURRELL, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BURRELL BEHAVIORAL HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 E BRADFORD PKWY | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658044264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4177615000 | ||||||||
| FaxNumber: | 4177615011 | ||||||||
| Practice Location | |||||||||
| Address1: | 1300 E BRADFORD PKWY | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658044264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4177615000 | ||||||||
| FaxNumber: | 4177615011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2007 | ||||||||
| LastUpdateDate: | 08/07/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CARTER | ||||||||
| AuthorizedOfficialFirstName: | AMANDA | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4177615126 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320900000X | N | Residential Treatment Facilities | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities | 261QM0855X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 876175019 | 05 | MO | MEDICAID |