Basic Information
| Provider Information | |||||||||
| NPI: | 1316926983 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MHC CHILD PROTECTION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1463 | ||||||||
| Address2: | |||||||||
| City: | SIOUX CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 511021463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122792263 | ||||||||
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| Practice Location | |||||||||
| Address1: | 801 5TH ST | ||||||||
| Address2: | |||||||||
| City: | SIOUX CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 511011394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122792548 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ROBERSON | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7122795850 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC2200X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
ID Information
| ID | Type | State | Issuer | Description | 0290858 | 05 | IA | MEDICAID | 29085 | 01 | IA | WELLMARK | OTHER |