Provider Demographics
NPI:1376698837
Name:WAUBONSIE MENTAL HEALTH CENTER INC
Entity Type:Organization
Organization Name:WAUBONSIE MENTAL HEALTH CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHOTWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-542-2388
Mailing Address - Street 1:216 W DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:CLARINDA
Mailing Address - State:IA
Mailing Address - Zip Code:51632-2509
Mailing Address - Country:US
Mailing Address - Phone:712-542-2388
Mailing Address - Fax:712-542-2984
Practice Address - Street 1:216 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:CLARINDA
Practice Address - State:IA
Practice Address - Zip Code:51632-2509
Practice Address - Country:US
Practice Address - Phone:712-542-2388
Practice Address - Fax:712-542-2984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0017244Medicaid
IA0229419Medicaid
IA0299446Medicaid
IA21525Medicare ID - Type Unspecified
IA0017244Medicaid