Provider Demographics
NPI:1790837805
Name:SPROUSE, DOUGLAS EDWARD (MASTERS IN SOCIAL WO)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:EDWARD
Last Name:SPROUSE
Suffix:
Gender:M
Credentials:MASTERS IN SOCIAL WO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3805 OAKLAND AVENUE
Mailing Address - Street 2:SUITE 102F
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506
Mailing Address - Country:US
Mailing Address - Phone:816-671-9604
Mailing Address - Fax:816-364-2158
Practice Address - Street 1:3805 OAKLAND AVENUE
Practice Address - Street 2:SUITE 102F
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506
Practice Address - Country:US
Practice Address - Phone:816-671-9604
Practice Address - Fax:816-364-2158
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO365101YA0400X
MO0010331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
19706028OtherBLUE CROSS BLUE SHIELD
MOR30671Medicare ID - Type Unspecified