Provider Demographics
NPI:1679099725
Name:EMBARK BY CALO
Entity type:Organization
Organization Name:EMBARK BY CALO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CECILY
Authorized Official - Middle Name:M
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-593-6376
Mailing Address - Street 1:P.O. BOX 1810
Mailing Address - Street 2:
Mailing Address - City:LAKE OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65049
Mailing Address - Country:US
Mailing Address - Phone:573-365-2221
Mailing Address - Fax:
Practice Address - Street 1:110 CROSSING DRIVE SUITE 1
Practice Address - Street 2:
Practice Address - City:LAKE OZARK
Practice Address - State:MO
Practice Address - Zip Code:65049
Practice Address - Country:US
Practice Address - Phone:573-365-2221
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHANGE ACADEMY AT LAKE OF THE OZARKS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-08-21
Last Update Date:2017-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012040525101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty