Provider Demographics
NPI:1669805826
Name:MIDWEST NEUROPSYCHOLOGY AND BEHAVIORAL HEALTH, LLC
Entity type:Organization
Organization Name:MIDWEST NEUROPSYCHOLOGY AND BEHAVIORAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NEUROPSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:GRANT
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:417-880-6838
Mailing Address - Street 1:1864 S KENTWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-2323
Mailing Address - Country:US
Mailing Address - Phone:417-880-6838
Mailing Address - Fax:417-374-0074
Practice Address - Street 1:1864 S KENTWOOD AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2323
Practice Address - Country:US
Practice Address - Phone:417-880-6838
Practice Address - Fax:417-374-0074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-12
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013020719103TC0700X, 103G00000X
MO20130154221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty