Provider Demographics
NPI:1457778110
Name:FAITHWALK COMMUNITY DEVELOPMENT CORPORATION
Entity type:Organization
Organization Name:FAITHWALK COMMUNITY DEVELOPMENT CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP-
Authorized Official - Prefix:MISS
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE PRACTIONER-LN#
Authorized Official - Phone:660-327-5752
Mailing Address - Street 1:P.O. BOX 119
Mailing Address - Street 2:514 FOX ST.
Mailing Address - City:PARIS
Mailing Address - State:MO
Mailing Address - Zip Code:65275
Mailing Address - Country:US
Mailing Address - Phone:660-327-5752
Mailing Address - Fax:660-327-6233
Practice Address - Street 1:514 FOX ST.
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:MO
Practice Address - Zip Code:65275
Practice Address - Country:US
Practice Address - Phone:660-327-5752
Practice Address - Fax:660-327-6233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-19
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101YM0800X, 101YP1600X
MO2004028021363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty