Provider Demographics
NPI:1114189180
Name:FAMILY INSTITUTE OF MENTAL HEALTH, INC.
Entity Type:Organization
Organization Name:FAMILY INSTITUTE OF MENTAL HEALTH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:BETSY
Authorized Official - Middle Name:HACKER
Authorized Official - Last Name:WAHL
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:417-588-2933
Mailing Address - Street 1:23175 PARADISE DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:MO
Mailing Address - Zip Code:65536-5146
Mailing Address - Country:US
Mailing Address - Phone:417-588-2933
Mailing Address - Fax:
Practice Address - Street 1:281 S JEFFERSON AVE
Practice Address - Street 2:SUITE J
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-3226
Practice Address - Country:US
Practice Address - Phone:417-588-2933
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000080251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1508837857Medicaid