Provider Demographics
NPI:1417902305
Name:NORTHWOODS PSYCHIATRIC SERVICES INC
Entity Type:Organization
Organization Name:NORTHWOODS PSYCHIATRIC SERVICES INC
Other - Org Name:POMME DE TERRE WELLNESS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DENESE
Authorized Official - Middle Name:
Authorized Official - Last Name:STRANGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-326-7272
Mailing Address - Street 1:PO BOX 49
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-0049
Mailing Address - Country:US
Mailing Address - Phone:417-326-7272
Mailing Address - Fax:417-326-2193
Practice Address - Street 1:1100 S SPRINGFIELD AVE STE B
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-2512
Practice Address - Country:US
Practice Address - Phone:417-326-7272
Practice Address - Fax:417-326-2193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004008720101YP2500X
MO2003024990101YP2500X
MOPY01322103TC0700X
MO20040154881041C0700X
MO2006004145207Q00000X
MOR1J412084P0800X
261QM0850X
MO066643363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO597191808Medicaid
MO597191808Medicaid
MO268929Medicare Oscar/Certification