Provider Demographics
NPI:1326897067
Name:VILLAGE LAKE
Entity type:Organization
Organization Name:VILLAGE LAKE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ANAIDY
Authorized Official - Middle Name:G
Authorized Official - Last Name:CLAUDIO ROSA
Authorized Official - Suffix:
Authorized Official - Credentials:LSCSW, LCAC
Authorized Official - Phone:316-284-7730
Mailing Address - Street 1:265 W VILLAGE LAKE DR
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037-2612
Mailing Address - Country:US
Mailing Address - Phone:316-284-7730
Mailing Address - Fax:
Practice Address - Street 1:345 RIVERVIEW ST. #730
Practice Address - Street 2:WICHITA
Practice Address - City:KS
Practice Address - State:KS
Practice Address - Zip Code:67203
Practice Address - Country:US
Practice Address - Phone:316-395-2886
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-15
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health