Basic Information
| Provider Information | |||||||||
| NPI: | 1598872442 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FLOOD | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 688 | ||||||||
| Address2: | |||||||||
| City: | INDEPENDENCE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 673010688 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3751 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | INDEPENDENCE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 673018446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6203311748 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 12/01/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 0253 | KS | Y | Behavioral Health & Social Service Providers | Psychologist | 101YA0400X | LAC 1073 | KS | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 200435650A | 05 | KS | MEDICAID |