Provider Demographics
NPI:1295239671
Name:WORTHON, FREDA ANNETTE (MED, LPC, LPN)
Entity type:Individual
Prefix:MRS
First Name:FREDA
Middle Name:ANNETTE
Last Name:WORTHON
Suffix:
Gender:F
Credentials:MED, LPC, LPN
Other - Prefix:MS
Other - First Name:FREDA
Other - Middle Name:A
Other - Last Name:MCCANTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1300 E BRADFORD PKWY
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-4264
Mailing Address - Country:US
Mailing Address - Phone:417-761-5000
Mailing Address - Fax:417-761-5011
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:417-761-5000
Practice Address - Fax:417-761-5011
Is Sole Proprietor?:No
Enumeration Date:2018-03-21
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO030489164W00000X
MO1999136664101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO494977416Medicaid