Provider Demographics
NPI:1780701029
Name:HART, NAN SUSAN (MS)
Entity type:Individual
Prefix:MRS
First Name:NAN
Middle Name:SUSAN
Last Name:HART
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2473 E EDGEWOOD ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-3905
Mailing Address - Country:US
Mailing Address - Phone:417-886-8273
Mailing Address - Fax:
Practice Address - Street 1:1550 E BATTLEFIELD ST
Practice Address - Street 2:SUITE A
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-3704
Practice Address - Country:US
Practice Address - Phone:417-869-9011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006009175101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO491221107Medicaid
MO2006009175OtherCOUNSELOR LICENSE NUMBER