Provider Demographics
NPI:1306872064
Name:FAMILY THERAPY INSTITUTE MIDWEST
Entity type:Organization
Organization Name:FAMILY THERAPY INSTITUTE MIDWEST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:LU
Authorized Official - Last Name:EGIDY
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:785-830-8299
Mailing Address - Street 1:2619 W. 6TH STREET, SUITE C
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66049
Mailing Address - Country:US
Mailing Address - Phone:785-830-8299
Mailing Address - Fax:785-749-2581
Practice Address - Street 1:2619 W. 6TH STREET, SUITE C
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66049
Practice Address - Country:US
Practice Address - Phone:785-830-8299
Practice Address - Fax:785-749-2581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS6890104100000X
KS46111163WP0807X
KS1109103TC2200X
KS17401041C0700X
KS35691041C0700X
KS74564163WP0807X
KS0894103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & AdolescentGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100389740AMedicaid
KS100353150AMedicaid
KS100353230AMedicaid
KS100297790CMedicaid