Provider Demographics
NPI:1891416426
Name:WORSTELL, BREANNA R
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:R
Last Name:WORSTELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BREANNA
Other - Middle Name:R
Other - Last Name:WATT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2526
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803-2526
Mailing Address - Country:US
Mailing Address - Phone:417-347-7579
Mailing Address - Fax:
Practice Address - Street 1:1949 SNOWBERRY LN
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-5420
Practice Address - Country:US
Practice Address - Phone:417-347-7579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20220338591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical