Provider Demographics
NPI:1033231303
Name:INDIVIDUAL EXPRESSIONS INC
Entity Type:Organization
Organization Name:INDIVIDUAL EXPRESSIONS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:FORTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-509-5509
Mailing Address - Street 1:8317 WOODSON DR
Mailing Address - Street 2:
Mailing Address - City:RAYTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:64138-3550
Mailing Address - Country:US
Mailing Address - Phone:816-356-3659
Mailing Address - Fax:816-356-1207
Practice Address - Street 1:507 SE 3RD ST
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64063-2810
Practice Address - Country:US
Practice Address - Phone:816-524-4745
Practice Address - Fax:816-524-4751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities