Basic Information
Provider Information | |||||||||
NPI: | 1811327950 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SEQUEL OF KANSAS, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LAKESIDE ACADEMY OF KANSAS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 24401 W MACARTHUR RD | ||||||||
Address2: | P.O. BOX 429 | ||||||||
City: | GODDARD | ||||||||
State: | KS | ||||||||
PostalCode: | 670528713 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3167942760 | ||||||||
FaxNumber: | 3167942773 | ||||||||
Practice Location | |||||||||
Address1: | 24401 W MACARTHUR RD | ||||||||
Address2: |   | ||||||||
City: | GODDARD | ||||||||
State: | KS | ||||||||
PostalCode: | 670528713 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3167942760 | ||||||||
FaxNumber: | 3167942773 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/26/2013 | ||||||||
LastUpdateDate: | 09/10/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CAUDLE | ||||||||
AuthorizedOfficialFirstName: | MARY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SENIOR DIRECTOR OF PATIENT ACCOUNTS | ||||||||
AuthorizedOfficialTelephone: | 2568803339 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/10/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | 0063040-008 | KS | N |   | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 322D00000X |   |   | Y |   | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |   |
No ID Information.