Provider Demographics
NPI:1326362708
Name:FOUR COUNTY MENTAL HEALTH CENTER
Entity Type:Organization
Organization Name:FOUR COUNTY MENTAL HEALTH CENTER
Other - Org Name:ACTIVE PARTNERS IN HOME SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:HENNEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-331-1748
Mailing Address - Street 1:PO BOX 688
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:KS
Mailing Address - Zip Code:67301-0688
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:415 FRUITLAND
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:KS
Practice Address - Zip Code:67301
Practice Address - Country:US
Practice Address - Phone:620-332-8584
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-15
Last Update Date:2011-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100097980WMedicaid