Provider Demographics
NPI:1972811198
Name:CROSSROADS OF PELLA
Entity Type:Organization
Organization Name:CROSSROADS OF PELLA
Other - Org Name:THE EDGE OF RECOVERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:EMILY
Authorized Official - Last Name:KAY
Authorized Official - Suffix:
Authorized Official - Credentials:MS ACADC
Authorized Official - Phone:641-780-1087
Mailing Address - Street 1:712 UNION STREET
Mailing Address - Street 2:
Mailing Address - City:PELLA
Mailing Address - State:IA
Mailing Address - Zip Code:50219
Mailing Address - Country:US
Mailing Address - Phone:641-628-1212
Mailing Address - Fax:641-628-3181
Practice Address - Street 1:103 NORTH 3RD STREET
Practice Address - Street 2:
Practice Address - City:OSKALOOSA
Practice Address - State:IA
Practice Address - Zip Code:52577
Practice Address - Country:US
Practice Address - Phone:641-676-4060
Practice Address - Fax:641-676-3721
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CROSSROADS OF PELLA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-09-22
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1339251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1339OtherADULT AND JUVENILE LEVEL I SUBSTANCE ABUSE TREATMENT SERVICES