Provider Demographics
NPI:1013096544
Name:STATE OF MISSOURI
Entity Type:Organization
Organization Name:STATE OF MISSOURI
Other - Org Name:COTTONWOOD RESIDENTIAL TREATMENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF ADMINSTRATIVE SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:MOLLY
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:BOECKMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-751-4055
Mailing Address - Street 1:PO BOX 687
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65102-0687
Mailing Address - Country:US
Mailing Address - Phone:573-751-3398
Mailing Address - Fax:573-526-4560
Practice Address - Street 1:1025 N SPRIGG ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-4831
Practice Address - Country:US
Practice Address - Phone:573-290-5888
Practice Address - Fax:573-290-5895
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF MISSOURI
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-03
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOEXEMPT323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO053445003Medicaid
MO873445001Medicaid