Provider Demographics
NPI:1245226745
Name:WUBBENHORST, JOHN MICHAEL SR (MS)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:MICHAEL
Last Name:WUBBENHORST
Suffix:SR
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 BROADWAY ST
Mailing Address - Street 2:SUITE 1104
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64111-2658
Mailing Address - Country:US
Mailing Address - Phone:816-753-3333
Mailing Address - Fax:616-753-7744
Practice Address - Street 1:3100 BROADWAY ST
Practice Address - Street 2:SUITE 1104
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-2658
Practice Address - Country:US
Practice Address - Phone:816-753-3333
Practice Address - Fax:616-753-7744
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOPY00348103T00000X, 103TC0700X, 103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service