Provider Demographics
NPI:1154863306
Name:NORTH CENTRAL MISSOURI MENTAL HEALTH CENTER
Entity Type:Organization
Organization Name:NORTH CENTRAL MISSOURI MENTAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LORYNE
Authorized Official - Middle Name:D
Authorized Official - Last Name:IRVINE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:660-359-4487
Mailing Address - Street 1:PO BOX 30
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:MO
Mailing Address - Zip Code:64683-0030
Mailing Address - Country:US
Mailing Address - Phone:660-359-4487
Mailing Address - Fax:660-359-4129
Practice Address - Street 1:1601 E 28TH ST
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MO
Practice Address - Zip Code:64683-1178
Practice Address - Country:US
Practice Address - Phone:660-359-4487
Practice Address - Fax:660-359-4129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-04
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
0020000AOtherPTAN
MO21371013OtherBLUE CROSS BLUE SHIELD