Provider Demographics
NPI:1902262991
Name:FORTITUDE INTENSIVE OUTPATIENT PROGRAM LLC
Entity Type:Organization
Organization Name:FORTITUDE INTENSIVE OUTPATIENT PROGRAM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHABANA
Authorized Official - Middle Name:
Authorized Official - Last Name:INSAF
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:417-243-7777
Mailing Address - Street 1:500 W MAIN ST
Mailing Address - Street 2:ST. 204
Mailing Address - City:BRANSON
Mailing Address - State:MO
Mailing Address - Zip Code:65616-2727
Mailing Address - Country:US
Mailing Address - Phone:417-243-7777
Mailing Address - Fax:417-243-7778
Practice Address - Street 1:500 W MAIN ST
Practice Address - Street 2:ST. 204
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-2727
Practice Address - Country:US
Practice Address - Phone:417-243-7777
Practice Address - Fax:417-243-7778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-07
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health