Provider Demographics
NPI:1750615829
Name:NORTHLAND BEHAVIORAL HEALTH & WELLNESS, LLC
Entity type:Organization
Organization Name:NORTHLAND BEHAVIORAL HEALTH & WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:M
Authorized Official - Last Name:SHOFFNER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:816-420-3130
Mailing Address - Street 1:119 NE 72ND ST
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:MO
Mailing Address - Zip Code:64118-1826
Mailing Address - Country:US
Mailing Address - Phone:816-420-3130
Mailing Address - Fax:816-734-0083
Practice Address - Street 1:119 NE 72ND ST
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:MO
Practice Address - Zip Code:64118-1826
Practice Address - Country:US
Practice Address - Phone:816-420-3130
Practice Address - Fax:816-734-0083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-23
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005004519103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty