Provider Demographics
NPI:1740052299
Name:BETTY LOU WALLACE RECOVERY
Entity type:Organization
Organization Name:BETTY LOU WALLACE RECOVERY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:O'GRADY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-599-7382
Mailing Address - Street 1:13340 HOLMES RD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64145
Mailing Address - Country:US
Mailing Address - Phone:816-599-7382
Mailing Address - Fax:816-599-7510
Practice Address - Street 1:13013 STATE LINE RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64145
Practice Address - Country:US
Practice Address - Phone:816-599-7382
Practice Address - Fax:816-599-7510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-27
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness