Provider Demographics
NPI:1285713289
Name:GREAT CIRCLE
Entity type:Organization
Organization Name:GREAT CIRCLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:KLIETHERMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-303-7219
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:SAINT JAMES
Mailing Address - State:MO
Mailing Address - Zip Code:65559-0189
Mailing Address - Country:US
Mailing Address - Phone:573-265-3251
Mailing Address - Fax:573-265-8571
Practice Address - Street 1:13160 COUNTY ROAD 3610
Practice Address - Street 2:
Practice Address - City:SAINT JAMES
Practice Address - State:MO
Practice Address - Zip Code:65559-0189
Practice Address - Country:US
Practice Address - Phone:573-265-3251
Practice Address - Fax:573-265-8571
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO430681470A251S00000X
MO000046739253J00000X, 323P00000X
261QM0850X, 261QM0855X
MO0A322D00000X
MO000045712323P00000X
MO000045767323P00000X
MO0000469461323P00000X
MO000363075323P00000X
MO001943115323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment FacilityGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No253J00000XAgenciesFoster Care AgencyGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Multi-Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Multi-Specialty
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed ChildrenGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO507009603Medicaid