Provider Demographics
NPI:1518168129
Name:MINIRTH SKIPPER CLINIC
Entity Type:Organization
Organization Name:MINIRTH SKIPPER CLINIC
Other - Org Name:MINIRTH SKIPPER COUNSELING CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORPORATE SECRETARY MYRA
Authorized Official - Prefix:MRS
Authorized Official - First Name:MYRA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SKIPPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-887-3822
Mailing Address - Street 1:2131 W REPUBLIC RD
Mailing Address - Street 2:#360
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1835 E REPUBLIC RD
Practice Address - Street 2:SUITE 204
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807
Practice Address - Country:US
Practice Address - Phone:417-887-3822
Practice Address - Fax:417-887-7773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty