Basic Information
| Provider Information | |||||||||
| NPI: | 1366480824 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DRINKWATER | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | RENE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GRAHAM | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | RENE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 635 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672033602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166607600 | ||||||||
| FaxNumber: | 3163837925 | ||||||||
| Practice Location | |||||||||
| Address1: | 7701 E KELLOGG DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672071706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166609600 | ||||||||
| FaxNumber: | 3166609660 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 3550 | KS | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 14810 | 01 | KS | PREFERRED HEALTH SYSTEMS | OTHER |