Provider Demographics
NPI:1225237993
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:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:FORTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-509-5509
Mailing Address - Street 1:507 SE 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64063-2810
Mailing Address - Country:US
Mailing Address - Phone:816-524-4745
Mailing Address - Fax:816-524-4751
Practice Address - Street 1:3817 WOODSON DRIVE
Practice Address - Street 2:
Practice Address - City:RAYTOWN
Practice Address - State:MO
Practice Address - Zip Code:64138
Practice Address - Country:US
Practice Address - Phone:816-509-5509
Practice Address - Fax:816-356-1207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities