Basic Information
Provider Information | |||||||||
NPI: | 1396860532 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UNITED METHODIST YOUTHVILLE INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | YOUTHVILLE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 900 W BROADWAY ST | ||||||||
Address2: |   | ||||||||
City: | NEWTON | ||||||||
State: | KS | ||||||||
PostalCode: | 671142037 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3162831950 | ||||||||
FaxNumber: | 3162839540 | ||||||||
Practice Location | |||||||||
Address1: | 713 E KANSAS PLZ STE 1 | ||||||||
Address2: |   | ||||||||
City: | GARDEN CITY | ||||||||
State: | KS | ||||||||
PostalCode: | 678465849 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6202717458 | ||||||||
FaxNumber: | 3162839540 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/20/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MONARES | ||||||||
AuthorizedOfficialFirstName: | DANY | ||||||||
AuthorizedOfficialMiddleName: | RAY | ||||||||
AuthorizedOfficialTitleorPosition: | PROVIDER RELATIONS MANAGER | ||||||||
AuthorizedOfficialTelephone: | 3162831950 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LBSW | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | 771-1 | KS | Y |   | Agencies | Case Management |   |
No ID Information.