Provider Demographics
NPI:1275777328
Name:DERBY EMOTIONAL WELLNESS
Entity Type:Organization
Organization Name:DERBY EMOTIONAL WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHD, LSCSW
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MYERS-LANDSVERK
Authorized Official - Suffix:
Authorized Official - Credentials:LSCSW
Authorized Official - Phone:316-788-1907
Mailing Address - Street 1:1721 E OSAGE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037-2290
Mailing Address - Country:US
Mailing Address - Phone:316-788-1907
Mailing Address - Fax:316-788-1941
Practice Address - Street 1:1721 E OSAGE
Practice Address - Street 2:SUITE 300
Practice Address - City:DERBY
Practice Address - State:KS
Practice Address - Zip Code:67037-2290
Practice Address - Country:US
Practice Address - Phone:316-788-1907
Practice Address - Fax:316-788-1941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-20
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1527104100000X, 1041C0700X
KS4695104100000X
KS74173163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Single Specialty