Provider Demographics
NPI:1821252255
Name:PRAIRIE VILLAGE BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:PRAIRIE VILLAGE BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:785-266-0031
Mailing Address - Street 1:PO BOX 3905
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66046-0905
Mailing Address - Country:US
Mailing Address - Phone:785-266-0031
Mailing Address - Fax:785-266-4225
Practice Address - Street 1:26431 W 109TH TER
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66061-8779
Practice Address - Country:US
Practice Address - Phone:785-266-0031
Practice Address - Fax:785-266-4225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-15
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0294103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO25212023OtherBCBS OF KANSAS CITY
KS119010OtherBCBS OF KANSAS
MO25212023OtherBCBS OF KANSAS CITY
MO25212023OtherBCBS OF KANSAS CITY
KS119010Medicare PIN