Basic Information
Provider Information | |||||||||
NPI: | 1942395082 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COUNTY OF SEDGWICK | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | COMCARE FAMILY AND CHILDRENS SERVICES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 271 W 3RD ST N STE 600 | ||||||||
Address2: |   | ||||||||
City: | WICHITA | ||||||||
State: | KS | ||||||||
PostalCode: | 672021223 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3166607600 | ||||||||
FaxNumber: | 3169415075 | ||||||||
Practice Location | |||||||||
Address1: | 350 S BROADWAY AVE | ||||||||
Address2: |   | ||||||||
City: | WICHITA | ||||||||
State: | KS | ||||||||
PostalCode: | 67202 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3166609600 | ||||||||
FaxNumber: | 3166609660 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/04/2006 | ||||||||
LastUpdateDate: | 05/21/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TAMMANY | ||||||||
AuthorizedOfficialFirstName: | JOAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 3166607600 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LMLP | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 1041C0700X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041S0200X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | School | 2084P0800X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 100237150F | 05 | KS |   | MEDICAID |