Provider Demographics
NPI:1306379482
Name:MINERAL AREA PSYCHIATRIC SERVICES LLC
Entity Type:Organization
Organization Name:MINERAL AREA PSYCHIATRIC SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PMHNP
Authorized Official - Prefix:MR
Authorized Official - First Name:GABRIEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:CRAWFORD
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:573-330-6468
Mailing Address - Street 1:203 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-1836
Mailing Address - Country:US
Mailing Address - Phone:573-664-1047
Mailing Address - Fax:
Practice Address - Street 1:203 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-1836
Practice Address - Country:US
Practice Address - Phone:573-664-1047
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-06
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1032972084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO160318081127359Medicaid
MO130100012Medicare PIN