Provider Demographics
NPI:1942342043
Name:CRAIGMYLE, BOBBI J (PSYD)
Entity Type:Individual
Prefix:
First Name:BOBBI
Middle Name:J
Last Name:CRAIGMYLE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:1312 E LARK ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-7351
Practice Address - Country:US
Practice Address - Phone:417-820-3707
Practice Address - Fax:417-820-7954
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000167697103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO83795OtherAR BLUE SHIELD #
MO495083016Medicaid
MO83795OtherAR BLUE SHIELD #