Provider Demographics
NPI:1689246464
Name:CLYNES, BREANNA M (LCSW)
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:M
Last Name:CLYNES
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 NE MISSOURI RD STE 307
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64086-4722
Mailing Address - Country:US
Mailing Address - Phone:816-839-9427
Mailing Address - Fax:
Practice Address - Street 1:200 NE MISSOURI RD STE 307
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64086-4722
Practice Address - Country:US
Practice Address - Phone:816-839-9427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-12
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
MO202102-78101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO06142021Medicaid