Provider Demographics
NPI:1700820099
Name:MIDWEST BEHAVIORAL HEALTH, LLC
Entity Type:Organization
Organization Name:MIDWEST BEHAVIORAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:JR
Authorized Official - Credentials:PSYD
Authorized Official - Phone:660-281-6601
Mailing Address - Street 1:116 S LINCOLN DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MO
Mailing Address - Zip Code:63379-1418
Mailing Address - Country:US
Mailing Address - Phone:636-528-1996
Mailing Address - Fax:636-528-1833
Practice Address - Street 1:116 S LINCOLN DR
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MO
Practice Address - Zip Code:63379-1418
Practice Address - Country:US
Practice Address - Phone:636-528-1996
Practice Address - Fax:636-528-1833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO504578303Medicaid
MO000014120Medicare ID - Type UnspecifiedPROVIDER NUMBER