Provider Demographics
NPI:1013086842
Name:BOYS AND GIRLS TOWN MISSOURI
Entity Type:Organization
Organization Name:BOYS AND GIRLS TOWN MISSOURI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:SHANK
Authorized Official - Suffix:
Authorized Official - Credentials:MSW,
Authorized Official - Phone:417-865-1646
Mailing Address - Street 1:412 CARDINAL CT
Mailing Address - Street 2:
Mailing Address - City:NIXA
Mailing Address - State:MO
Mailing Address - Zip Code:65714-8848
Mailing Address - Country:US
Mailing Address - Phone:417-725-8684
Mailing Address - Fax:
Practice Address - Street 1:1212 W LOMBARD ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65806-2720
Practice Address - Country:US
Practice Address - Phone:417-865-1646
Practice Address - Fax:417-866-1483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2009-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002002751322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO494901309Medicaid