NPIMap

Organization Active NPI

State of Missouri

Doing business as Northwest MO Psychiatric Rehabilitation Center

  • Psychiatry Physician
  • Saint Joseph, MO
National Provider Identifier
1386691657
Registry record updated Sep 3, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatry PhysicianTaxonomy code 2084P0800X
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 30, 2006
Last updated
Sep 3, 2020By the provider in NPPES
Organization subpart
Yes
Parent organization
STATE OF MISSOURIAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Sep 3, 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 3

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical Psychologist 103TC0700X
Family Medicine Physician 207Q00000X
Psychiatry Physician 2084P0800X Primary

Addresses

Primary practice location

3505 Frederick Ave
Saint Joseph, MO 64506-2914

Mailing address

1706 E Elm St
Jefferson City, MO 65101-4130
Phone (573) 751-3398

Other identifiers 1

IdentifierTypeStateIssuer
500157706MedicaidMO

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
O20040609001176 MO Part B Supplier - Clinic/Group Practice 1456254226 Receives reassigned benefits from 18 practitioners
6 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Kansas City, MO; Marshall, MO; Nevada, MO; Saint Joseph, MO; Higginsville, MO

Other NPIs on the same Medicare enrollment 6

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Part of
Western Missouri Mental Health Center

Practitioners & affiliated clinicians

Practitioners 15

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.

View all 15

NPI Registry JSON

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

{
    "created_epoch": "1148947200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1599091200000",
    "number": "1386691657",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1706 E ELM ST",
            "city": "JEFFERSON CITY",
            "state": "MO",
            "postal_code": "651014130",
            "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": "2006-05-30",
        "last_updated": "2020-09-03",
        "certification_date": "2020-09-03",
        "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": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "500157706",
            "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

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 3, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.