Provider Demographics
NPI:1730258930
Name:NORTH CENTRAL MISSOURI MENTAL HEALTH CENTER
Entity type:Organization
Organization Name:NORTH CENTRAL MISSOURI MENTAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:LORYNE
Authorized Official - Middle Name:D
Authorized Official - Last Name:IRVINE
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LCSW
Authorized Official - Phone:660-359-4487
Mailing Address - Street 1:PO BOX 30
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:MO
Mailing Address - Zip Code:64683-0030
Mailing Address - Country:US
Mailing Address - Phone:660-359-4487
Mailing Address - Fax:660-359-4129
Practice Address - Street 1:1601 E 28TH ST
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MO
Practice Address - Zip Code:64683-1178
Practice Address - Country:US
Practice Address - Phone:660-359-4487
Practice Address - Fax:660-359-2958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO215-7709103T00000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
21371013OtherBLUE CROSS BLUE SHIELD
MO563012905Medicaid
083296OtherVALUE OPTIONS
MO563012905Medicaid
MO0020000AMedicare ID - Type Unspecified