Basic Information
| Provider Information | |||||||||
| NPI: | 1417332230 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEW LEAF THERAPY CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1204 SE LOUIS DR | ||||||||
| Address2: | |||||||||
| City: | MULVANE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 671101113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3163518696 | ||||||||
| FaxNumber: | 8445810869 | ||||||||
| Practice Location | |||||||||
| Address1: | 1204 SE LOUIS DR | ||||||||
| Address2: | |||||||||
| City: | MULVANE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 671101113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3163518696 | ||||||||
| FaxNumber: | 8445810869 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2015 | ||||||||
| LastUpdateDate: | 07/22/2015 | ||||||||
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| AuthorizedOfficialLastName: | DUTCHER | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3163518696 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PSYD, LP, LCMFT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 812 | KS | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 103TC0700X | 1982 | KS | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.