Provider Demographics
NPI:1609528835
Name:CROSSETT, BROGAN BLACK (LMLP)
Entity Type:Individual
Prefix:
First Name:BROGAN
Middle Name:BLACK
Last Name:CROSSETT
Suffix:
Gender:F
Credentials:LMLP
Other - Prefix:
Other - First Name:BROGAN
Other - Middle Name:
Other - Last Name:HOOVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMLP
Mailing Address - Street 1:436 HUNTINGTON RD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64113-1414
Mailing Address - Country:US
Mailing Address - Phone:913-488-6525
Mailing Address - Fax:816-227-6931
Practice Address - Street 1:9200 INDIAN CREEK PKWY STE 660
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66210-2097
Practice Address - Country:US
Practice Address - Phone:913-488-6525
Practice Address - Fax:816-227-6931
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-19
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS03090103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty