Provider Demographics
NPI:1073066320
Name:MAMMADOVA, DEBRA R (LP)
Entity Type:Individual
Prefix:DR
First Name:DEBRA
Middle Name:R
Last Name:MAMMADOVA
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:DEBRA
Other - Middle Name:R
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2400 LINDEN DR
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66106-4427
Mailing Address - Country:US
Mailing Address - Phone:414-839-4579
Mailing Address - Fax:
Practice Address - Street 1:117 S LEXINGTON ST STE 100
Practice Address - Street 2:
Practice Address - City:HARRISONVILLE
Practice Address - State:MO
Practice Address - Zip Code:64701-2444
Practice Address - Country:US
Practice Address - Phone:414-839-4579
Practice Address - Fax:855-202-6591
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-03
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018042701103TC0700X
KS02979103TC0700X
KS2713103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS20113801BMedicaid
MO490057295Medicaid