Provider Demographics
NPI:1962472670
Name:BREWER, RICHARD LYNN (PSYD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:LYNN
Last Name:BREWER
Suffix:
Gender:M
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 100
Mailing Address - Street 2:
Mailing Address - City:PIERCE CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65723-2100
Mailing Address - Country:US
Mailing Address - Phone:417-476-1013
Mailing Address - Fax:417-476-1082
Practice Address - Street 1:315 S MAIN AVE
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-2052
Practice Address - Country:US
Practice Address - Phone:417-326-2902
Practice Address - Fax:417-326-4555
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01577103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2970OtherBLUE CROSS BLUE SHIELD
MO496642505Medicaid
MO000070474Medicare ID - Type Unspecified