Provider Demographics
NPI:1649453663
Name:NORTHLAND PSYCHOLOGICAL ASSOCIATES LLC
Entity type:Organization
Organization Name:NORTHLAND PSYCHOLOGICAL ASSOCIATES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:C
Authorized Official - Last Name:DIPOTO
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:816-268-8501
Mailing Address - Street 1:9 VICTORY DR STE 2B
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-3807
Mailing Address - Country:US
Mailing Address - Phone:816-268-8501
Mailing Address - Fax:816-452-5700
Practice Address - Street 1:9 VICTORY DR STE 3
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068-3807
Practice Address - Country:US
Practice Address - Phone:816-268-8501
Practice Address - Fax:816-452-5700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-13
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA1805Medicare PIN