Provider Demographics
NPI:1770311037
Name:CRISENBERRY, MIMI (PLPC)
Entity type:Individual
Prefix:
First Name:MIMI
Middle Name:
Last Name:CRISENBERRY
Suffix:
Gender:F
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13521 SHORT CIR
Mailing Address - Street 2:
Mailing Address - City:SMITHVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64089-7819
Mailing Address - Country:US
Mailing Address - Phone:720-251-5246
Mailing Address - Fax:
Practice Address - Street 1:17 E KANSAS ST STE 200
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068-2372
Practice Address - Country:US
Practice Address - Phone:816-287-0001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-26
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024008501101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health