Provider Demographics
NPI:1750351409
Name:SPOONER, JOHN RICHARD (PSYD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:RICHARD
Last Name:SPOONER
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 1:2085 S BOSTON PL
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-2871
Mailing Address - Country:US
Mailing Address - Phone:417-326-2418
Mailing Address - Fax:417-326-2419
Practice Address - Street 1:2085 S BOSTON PL
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-2871
Practice Address - Country:US
Practice Address - Phone:417-326-2418
Practice Address - Fax:417-326-2419
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002023735101YP2500X
MO2006034106103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO495966319Medicaid
MO193564OtherBLUE CROSS BLUE SHIELD