Provider Demographics
NPI:1598290074
Name:PLAZA THERAPY GROUP LLC
Entity Type:Organization
Organization Name:PLAZA THERAPY GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:WIETHAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW LSCSW
Authorized Official - Phone:917-664-6530
Mailing Address - Street 1:4635 WYANDOTTE ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64112-1509
Mailing Address - Country:US
Mailing Address - Phone:917-664-6530
Mailing Address - Fax:
Practice Address - Street 1:4635 WYANDOTTE ST
Practice Address - Street 2:SUITE 205
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64112-1509
Practice Address - Country:US
Practice Address - Phone:917-664-6530
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-21
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20080334401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty