Provider Demographics
NPI:1023462058
Name:HEARTLAND CENTER FOR BEHAVIORAL CHANGE
Entity type:Organization
Organization Name:HEARTLAND CENTER FOR BEHAVIORAL CHANGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MYRNA
Authorized Official - Middle Name:
Authorized Official - Last Name:TRICKEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-421-6670
Mailing Address - Street 1:1730 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64127-2544
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1730 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64127-2544
Practice Address - Country:US
Practice Address - Phone:816-421-6670
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-15
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1053587469Medicaid
MO867762106Medicaid