Provider Demographics
NPI:1396004990
Name:CULTIVATE PSYCHOLOGICAL SERVICES LLC
Entity Type:Organization
Organization Name:CULTIVATE PSYCHOLOGICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST/OWNER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:FARNAN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:417-619-9818
Mailing Address - Street 1:331 E WATER ST
Mailing Address - Street 2:SUITE 107
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65806-1141
Mailing Address - Country:US
Mailing Address - Phone:417-619-4466
Mailing Address - Fax:
Practice Address - Street 1:1439 S ROGERS AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-1129
Practice Address - Country:US
Practice Address - Phone:417-619-9818
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-16
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009030819103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1962737734Medicaid
MA1019011OtherMEDICARE I.D. NUMBER