Provider Demographics
NPI:1780848747
Name:MONITEAU MENTAL HEALTH CARE
Entity Type:Organization
Organization Name:MONITEAU MENTAL HEALTH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:SHUCK
Authorized Official - Suffix:
Authorized Official - Credentials:APRN-PMH
Authorized Official - Phone:573-796-2905
Mailing Address - Street 1:PO BOX 5111
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-5111
Mailing Address - Country:US
Mailing Address - Phone:417-429-2180
Mailing Address - Fax:417-832-9799
Practice Address - Street 1:320 S OAK ST
Practice Address - Street 2:
Practice Address - City:CALIFORNIA
Practice Address - State:MO
Practice Address - Zip Code:65018-1824
Practice Address - Country:US
Practice Address - Phone:573-230-1037
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-17
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000161947364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO427531801Medicaid
MO835025362Medicare PIN