State of Missouri

Primary specialty

Intellectual and/or Developmental Disabilities Community Based Residential Treatment FacilityTaxonomy code 320900000X

Legal business name

STATE OF MISSOURI

Doing business as

Southeast Missouri Residential Services ISL

Practice address

2351 Kanell Blvd
Poplar Bluff, MO 63901-4035

Phone

(573) 840-9374

NPI assigned

Mar 9, 2009

Last updated

Sep 3, 2020By the provider in NPPES

Organization subpart

Yes

Parent organization

STATE OF MISSOURIAs reported in NPPES

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

Addresses

Other names 1

• Southeast Missouri Residential Services ISL Doing business as

Tax ID family

Missouri Tuberculosis Lab104 organizations share this tax ID, including this one

Part of

Missouri Tuberculosis Lab

Organizations with this tax ID in the same state 24

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

• Southeast Missouri Residential Services

  • Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
  • Poplar Bluff, MO
  • NPI 1568601482
  NPD tax ID
• State of Missouri

  dba Hannibal Regional Center

  • Developmentally Disabled Services Day Training Agency
  • Hannibal, MO
  • NPI 1487714515
  NPD tax ID
• State of Missouri

  dba Hawthorn Children's Psychiatric Hosptial

  • Psychiatric Residential Treatment Facility
  • Saint Louis, MO
  • NPI 1487721379
  NPD tax ID
• State of Missouri

  dba Higginsville Habilitation Center-Crisis

  • Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
  • Higginsville, MO
  • NPI 1487931358
  NPD tax ID
• State of Missouri

  dba Marshall Habilitation Center-Home 1

  • Developmentally Disabled Services Day Training Agency
  • Marshall, MO
  • NPI 1518027127
  NPD tax ID
• State of Missouri

  dba Nevada Habilitation Center-Crisis

  • Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
  • Nevada, MO
  • NPI 1528333085
  NPD tax ID
• State of Missouri

  dba Southeast Missouri Residential Services-Sikeston Prof Grp

  • Family Medicine Physician
  • Sikeston, MO
  • NPI 1528348430
  NPD tax ID
• State of Missouri

  dba Central Missouri Regional Center

  • Developmentally Disabled Services Day Training Agency
  • Columbia, MO
  • NPI 1548322605
  NPD tax ID
• State of Missouri

  dba CPR Youth

  • Rehabilitation Psychologist
  • Jefferson City, MO
  • NPI 1578199238
  NPD tax ID
• State of Missouri

  dba St Louis Forensic Treatment Center

  • Psychiatric Hospital
  • Saint Louis, MO
  • NPI 1578518239
  NPD tax ID
• State of Missouri

  dba Kirksville Regional Center

  • Developmentally Disabled Services Day Training Agency
  • Kirksville, MO
  • NPI 1578623609
  NPD tax ID
• State of Missouri

  dba Southeast Missouri Residential Services-Sikeston

  • Intellectual Disabilities Intermediate Care Facility
  • Sikeston, MO
  • NPI 1598844029
  NPD tax ID

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

{
    "created_epoch": "1236556800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1599091200000",
    "number": "1598906372",
    "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": "2351 KANELL BLVD",
            "city": "POPLAR BLUFF",
            "state": "MO",
            "postal_code": "639014035",
            "telephone_number": "573-840-9374"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "STATE OF MISSOURI",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "STATE OF MISSOURI",
        "enumeration_date": "2009-03-09",
        "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": "320900000X",
            "taxonomy_group": "",
            "desc": "Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Southeast Missouri Residential Services ISL",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Southeast Missouri Residential Services ISL",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Candice Dawn Stansfield, APRN-BC, FNP
• Stacey Diane Stark, FNP
• State of Missouri (Poplar Bluff Regional Center)
• State of Missouri (Southeast Missouri Residential Services-Poplar Bluff)
• State of Missouri (Poplar Bluff Regional Center)
• State of Missouri (Southeast Missouri Residential Services-Poplar Bluff Prof Grp)
• Katlynn Mae Steers
• Holly Renee' Steimel, MSE
• Gracie Stephens
• Miranda Ann Stevens

• Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility in Poplar Bluff, MO
• Providers in Poplar Bluff, MO by specialty
• Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility in Missouri

• 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.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.