Provider Demographics
NPI:1578864674
Name:FREDA WORTHON, M.ED LICENSE PROFESSIONAL COUNSELOR
Entity Type:Organization
Organization Name:FREDA WORTHON, M.ED LICENSE PROFESSIONAL COUNSELOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSE PROFESSIONAL COUNSELOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:FREDA
Authorized Official - Middle Name:ANNETTE
Authorized Official - Last Name:WORTHON
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:417-881-1249
Mailing Address - Street 1:5793 S MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65810-2593
Mailing Address - Country:US
Mailing Address - Phone:417-881-1249
Mailing Address - Fax:417-881-1249
Practice Address - Street 1:5793 S MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65810-2593
Practice Address - Country:US
Practice Address - Phone:417-881-1249
Practice Address - Fax:417-881-1249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-06
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1999136664276400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO494977416Medicaid