Basic Information
| Provider Information | |||||||||
| NPI: | 1679099725 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EMBARK BY CALO | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 1810 | ||||||||
| Address2: | |||||||||
| City: | LAKE OZARK | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733652221 | ||||||||
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| Practice Location | |||||||||
| Address1: | 110 CROSSING DRIVE SUITE 1 | ||||||||
| Address2: | |||||||||
| City: | LAKE OZARK | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733652221 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2017 | ||||||||
| LastUpdateDate: | 08/21/2017 | ||||||||
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| AuthorizedOfficialLastName: | MITCHELL | ||||||||
| AuthorizedOfficialFirstName: | CECILY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9135936376 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CHANGE ACADEMY AT LAKE OF THE OZARKS, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 2012040525 | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.