Provider Demographics
NPI:1770749079
Name:BETHANY CHRISTIAN SERVICES
Entity type:Organization
Organization Name:BETHANY CHRISTIAN SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MISSOURI BRANCH DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC
Authorized Official - Phone:314-781-6363
Mailing Address - Street 1:PO BOX 207
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MO
Mailing Address - Zip Code:63755-0207
Mailing Address - Country:US
Mailing Address - Phone:573-204-8800
Mailing Address - Fax:573-204-8833
Practice Address - Street 1:210 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MO
Practice Address - Zip Code:63755-1448
Practice Address - Country:US
Practice Address - Phone:573-204-8800
Practice Address - Fax:573-204-8833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-06
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO001523101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1780777250Medicaid