Provider Demographics
NPI:1356937783
Name:CROSS, MANDY GAIL (BA)
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:GAIL
Last Name:CROSS
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:MANDY
Other - Middle Name:GAIL
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:925 STATE HWY V V
Mailing Address - Street 2:
Mailing Address - City:KENNETT
Mailing Address - State:MO
Mailing Address - Zip Code:63857-0071
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3411 DIVISION DR
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-5789
Practice Address - Country:US
Practice Address - Phone:417-257-9152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-20
Last Update Date:2020-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician