NPIMap

Organization Active NPI

State of Missouri

Doing business as Northwest MO Psychiatric Rehabilitation Center

  • Psychiatric Hospital
  • Saint Joseph, MO
National Provider Identifier
1104879444
Registry record updated Oct 27, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatric HospitalTaxonomy code 283Q00000X
License
EXEMPT Issued in MO
Legal business name
STATE OF MISSOURI
Doing business as
Northwest MO Psychiatric Rehabilitation Center
Practice address
3505 Frederick Ave
Saint Joseph, MO 64506-2914
Phone
(816) 387-2300
Fax
(816) 387-2329
NPI assigned
May 18, 2006
Last updated
Oct 27, 2020By the provider in NPPES
Organization subpart
Yes
Parent organization
STATE OF MISSOURIAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Oct 27, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Molly Jane Boeckmann
Title
Director of Administrative Services
Phone
(573) 751-4055

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Psychiatric Hospital 283Q00000X EXEMPT MO Primary

Addresses

Primary practice location

3505 Frederick Ave
Saint Joseph, MO 64506-2914

Mailing address

PO Box 687
Jefferson City, MO 65102-0687
Phone (573) 751-3398

Other identifiers 1

IdentifierTypeStateIssuer
050157700MedicaidMO

Other names 1

  • Northwest MO Psychiatric Rehabilitation Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MO

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20071120000193 MO Part A Provider - Hospital 1456254226 Practice locations: Saint Joseph, MO

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1104879444. Details of each certification follow.

Hospital certification: CCN 264007

Legal name
STATE OF MISSOURI
Doing business as
NORTHWEST MISSOURI PSYCHIATRIC REHABILITATION CENTER
Certification status
Active
Provider type (POS)
Hospital – Psychiatric
Participating since
Jul 1, 1966
Last certification
Sep 10, 2003
Beds
142 (20 certified)
Ownership / control type
State
Organization structure
GovernmentNon-profit
Enrollment address
3505 Frederick Ave
Saint Joseph, MO 64506-2914
Other Hospital Practice Location
Hospital subgroups
Psychiatric

Other NPIs with the same Medicare PAC ID 11

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Care Compare: Hospital

Medicare Care Compare
Listed as
Northwest Missouri Psychiatric Rehab CtrCCN 264007 · All quality measures
Type
Psychiatric
Ownership
Government - State
Medicare certification status
ActiveFrom the Provider of Services file
Emergency services
No

National Provider Directory

National Provider Directory
Tax ID family
Western Missouri Mental Health Center104 organizations share this tax ID, including this one
Part of
Western Missouri Mental Health Center

Organizations with this tax ID in the same state 18

This tax ID family is large, so up to 24 of its organizations in the same state are linked here.

View all 18

Locations

3505 Frederick Ave
Saint Joseph, MO 64506
Phone (816) 387-2300

Ownership & related parties

All disclosed owners & managing parties 7

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Molly Boeckmann Individual Corporate Director Jul 1, 2020
W-2 Managing Employee Jul 1, 2020
State of Missouri Organization, Jefferson City, MO 5% Or Greater Direct Ownership Interest Jan 1, 1966 100%
Operational/Managerial Control Jan 1, 1966 100%
Tyler Rinehart Individual W-2 Managing Employee Jul 1, 2019
Gloria Gehlert Individual W-2 Managing EmployeeReimbursement Administrator Apr 29, 2013
Becky D Norbury Individual W-2 Managing EmployeeRegional Executive Officer Jan 1, 2014
Tara Tubbesing Individual Corporate OfficerChief Operating Officer Jul 1, 2019
Donna S Siebeneck Individual W-2 Managing EmployeeMedicaid Liasion Oct 1, 2014

Owners & managing parties with NPI records 11

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

  • State of Missouri

    dba Hawthorn Children's Psychiatric Hosptial

    • Psychiatric Hospital
    • Saint Louis, MO
    • NPI 1033289897

    5% Or Greater Direct Ownership Interest, Operational/Managerial Control

    CMS ownership
  • State of Missouri

    dba Fulton State Hospital

    • Psychiatric Hospital
    • Fulton, MO
    • NPI 1104878792

    5% Or Greater Direct Ownership Interest, Operational/Managerial Control

    CMS ownership
  • State of Missouri

    dba Fulton State Hospital

    • Psychiatry Physician
    • Fulton, MO
    • NPI 1164477873

    5% Or Greater Direct Ownership Interest, Operational/Managerial Control

    CMS ownership
  • State of Missouri

    dba St. Louis Developmental Disabilities Treatment Center

    • General Practice Physician
    • Saint Charles, MO
    • NPI 1316991896

    5% Or Greater Direct Ownership Interest, Operational/Managerial Control

    CMS ownership
  • State of Missouri

    dba St Louis Forensic Treatment Center

    • Psychiatry Physician
    • Saint Louis, MO
    • NPI 1427002013

    5% Or Greater Direct Ownership Interest, Operational/Managerial Control

    CMS ownership
  • State of Missouri

    dba Southeast MO Mental Health Center

    • Psychiatry Physician
    • Farmington, MO
    • NPI 1437106705

    5% Or Greater Direct Ownership Interest, Operational/Managerial Control

    CMS ownership
  • State of Missouri

    dba Center for Behavioral Health

    • Psychiatry Physician
    • Kansas City, MO
    • NPI 1497709083

    5% Or Greater Direct Ownership Interest, Operational/Managerial Control

    CMS ownership
  • State of Missouri

    dba St Louis Forensic Treatment Center

    • Psychiatric Hospital
    • Saint Louis, MO
    • NPI 1578518239

    5% Or Greater Direct Ownership Interest, Operational/Managerial Control

    CMS ownership
  • State of Missouri

    dba Bellefontaine Habilitation Center

    • Physical Medicine & Rehabilitation Physician
    • Saint Louis, MO
    • NPI 1710931167

    5% Or Greater Direct Ownership Interest, Operational/Managerial Control

    CMS ownership
  • State of Missouri

    dba Center for Behavioral Medicine

    • Psychiatric Hospital
    • Kansas City, MO
    • NPI 1730134495

    5% Or Greater Direct Ownership Interest, Operational/Managerial Control

    CMS ownership
  • State of Missouri

    dba Southeast MO Mental Health Center

    • Psychiatric Hospital
    • Farmington, MO
    • NPI 1861447526

    5% Or Greater Direct Ownership Interest, Operational/Managerial Control

    CMS ownership

All facility ownership & control disclosures 5

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Center for Behavioral MedicineKansas City, MO, CCN 264008 Hospital 5% Or Greater Direct Ownership Interest (100%) Jul 1, 1966
St Louis Forensic Treatment CenterSaint Louis, MO, CCN 264010 Hospital 5% Or Greater Direct Ownership Interest (100%) Jul 1, 1966
Southeast Missouri Mental Health CenterFarmington, MO, CCN 264005 Hospital 5% Or Greater Direct Ownership Interest (100%) Jul 1, 1966
Fulton State HospitalFulton, MO, CCN 264004 Hospital 5% Or Greater Direct Ownership Interest (100%) Jul 1, 1966
Hawthorn Children's Psychiatric HospitalSaint Louis, MO, CCN 264028 Hospital 5% Or Greater Direct Ownership Interest (100%) Jul 1, 1981

Owned or controlled facilities with NPI records 5

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

  • State of Missouri

    dba Hawthorn Children's Psychiatric Hosptial

    • Psychiatric Hospital
    • Saint Louis, MO
    • NPI 1033289897

    5% Or Greater Direct Ownership Interest

    CMS ownership
  • State of Missouri

    dba Fulton State Hospital

    • Psychiatric Hospital
    • Fulton, MO
    • NPI 1104878792

    5% Or Greater Direct Ownership Interest

    CMS ownership
  • State of Missouri

    dba St Louis Forensic Treatment Center

    • Psychiatric Hospital
    • Saint Louis, MO
    • NPI 1578518239

    5% Or Greater Direct Ownership Interest

    CMS ownership
  • State of Missouri

    dba Center for Behavioral Medicine

    • Psychiatric Hospital
    • Kansas City, MO
    • NPI 1730134495

    5% Or Greater Direct Ownership Interest

    CMS ownership
  • State of Missouri

    dba Southeast MO Mental Health Center

    • Psychiatric Hospital
    • Farmington, MO
    • NPI 1861447526

    5% Or Greater Direct Ownership Interest

    CMS ownership

Facilities with the same owner 5

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1147910400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1603756800000",
    "number": "1104879444",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 687",
            "city": "JEFFERSON CITY",
            "state": "MO",
            "postal_code": "651020687",
            "telephone_number": "573-751-3398",
            "fax_number": "573-526-4560"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3505 FREDERICK AVE",
            "city": "SAINT JOSEPH",
            "state": "MO",
            "postal_code": "645062914",
            "telephone_number": "816-387-2300",
            "fax_number": "816-387-2329"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "STATE OF MISSOURI",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "STATE OF MISSOURI",
        "enumeration_date": "2006-05-18",
        "last_updated": "2020-10-27",
        "certification_date": "2020-10-27",
        "status": "A",
        "authorized_official_last_name": "BOECKMANN",
        "authorized_official_first_name": "MOLLY",
        "authorized_official_middle_name": "JANE",
        "authorized_official_title_or_position": "DIRECTOR OF ADMINISTRATIVE SERVICES",
        "authorized_official_telephone_number": "573-751-4055"
    },
    "taxonomies": [
        {
            "code": "283Q00000X",
            "taxonomy_group": "",
            "desc": "Psychiatric Hospital",
            "state": "MO",
            "license": "EXEMPT",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "050157700",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Northwest MO Psychiatric Rehabilitation Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Northwest MO Psychiatric Rehabilitation Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Saint Joseph, MO

Sources for this page

Verify at the official NPI Registry.