Provider Demographics
NPI:1487650842
Name:HERITAGE MENTAL HEALTH CLINIC, LLC
Entity Type:Organization
Organization Name:HERITAGE MENTAL HEALTH CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DORA
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:785-272-5566
Mailing Address - Street 1:2110 SW BELLE AVE STE B
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66614-1773
Mailing Address - Country:US
Mailing Address - Phone:785-272-5566
Mailing Address - Fax:785-272-5967
Practice Address - Street 1:2110 SW BELLE AVE STE B
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66614-1773
Practice Address - Country:US
Practice Address - Phone:785-272-5566
Practice Address - Fax:785-272-5967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-21
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS311103TC0700X
KS13661041C0700X
KS04-205372084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS110649Medicare ID - Type Unspecified