Provider Demographics
NPI:1265556633
Name:COLVIN, ANNE R (PSYD)
Entity type:Individual
Prefix:DR
First Name:ANNE
Middle Name:R
Last Name:COLVIN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:ANNE
Other - Middle Name:R
Other - Last Name:LARSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3610 N. 30TH STREET
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65721
Mailing Address - Country:US
Mailing Address - Phone:417-655-3402
Mailing Address - Fax:
Practice Address - Street 1:1300 E BRADFORD PKWY
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-4264
Practice Address - Country:US
Practice Address - Phone:417-269-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006011178101YP2500X
MO2007025029103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1265556633Medicaid
MO1265556633Medicaid