Basic Information
| Provider Information | |||||||||
| NPI: | 1265800304 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ECKELBERRY | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | ANDREW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 517 STONE POINTE DR | ||||||||
| Address2: | |||||||||
| City: | MANHATTAN | ||||||||
| State: | KS | ||||||||
| PostalCode: | 665030431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7855647208 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1106 N 155TH ST | ||||||||
| Address2: | B | ||||||||
| City: | BASEHOR | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660077100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9136627071 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2015 | ||||||||
| LastUpdateDate: | 09/07/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 48-1284001 | 01 | KS | CASE MAN./ CARE COORD. | OTHER |