Provider Demographics
NPI:1578057220
Name:PRYOR, MERISSA
Entity Type:Individual
Prefix:
First Name:MERISSA
Middle Name:
Last Name:PRYOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 CONESTOGA DRIVE, MBN 120
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711
Mailing Address - Country:US
Mailing Address - Phone:217-220-5392
Mailing Address - Fax:
Practice Address - Street 1:4200 CONESTOGA DRIVE, MBN 120
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62711
Practice Address - Country:US
Practice Address - Phone:217-220-5392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-17
Last Update Date:2020-11-21
Deactivation Date:2018-07-31
Deactivation Code:
Reactivation Date:2019-10-10
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
IL149.0192501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical