Provider Demographics
NPI:1942550322
Name:KASEY GRASS PHD LLC
Entity Type:Organization
Organization Name:KASEY GRASS PHD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KASEY
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:GRASS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:501-993-2274
Mailing Address - Street 1:2761 E MELBOURNE RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-5257
Mailing Address - Country:US
Mailing Address - Phone:501-993-2274
Mailing Address - Fax:888-389-4091
Practice Address - Street 1:2401 W GRAND ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802-4967
Practice Address - Country:US
Practice Address - Phone:501-993-2274
Practice Address - Fax:888-389-4091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-13
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011019654251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1073805909Medicaid