Basic Information
| Provider Information | |||||||||
| NPI: | 1780965509 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY THERAPY OF THE OZARKS, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1310 E KINGSLEY ST | ||||||||
| Address2: | SUITE C | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658047216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178827700 | ||||||||
| FaxNumber: | 4178853956 | ||||||||
| Practice Location | |||||||||
| Address1: | 1310 E. KINGSLEY | ||||||||
| Address2: | SUITE C | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658047238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178827700 | ||||||||
| FaxNumber: | 4178853956 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2011 | ||||||||
| LastUpdateDate: | 11/30/2017 | ||||||||
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| AuthorizedOfficialLastName: | BOLING | ||||||||
| AuthorizedOfficialFirstName: | CATHERINE | ||||||||
| AuthorizedOfficialMiddleName: | LEA | ||||||||
| AuthorizedOfficialTitleorPosition: | CO-OWNER/THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 4178827700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MSW, LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1780965509 | 05 | MO | MEDICAID | 1346412327 | 05 | MO | MEDICAID |