Basic Information
| Provider Information | |||||||||
| NPI: | 1508980970 | ||||||||
| 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: | 4505 E 47TH ST S | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672101651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3165299100 | ||||||||
| FaxNumber: | 3165299351 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2007 | ||||||||
| 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.