Provider Demographics
NPI:1831628023
Name:GRAGG-PYATT, GAELYN L (MS LPC)
Entity type:Individual
Prefix:
First Name:GAELYN
Middle Name:L
Last Name:GRAGG-PYATT
Suffix:
Gender:F
Credentials:MS LPC
Other - Prefix:
Other - First Name:GAELYN
Other - Middle Name:L
Other - Last Name:GRAGG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, PLPC
Mailing Address - Street 1:1300 E BRADFORD PKWY
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-4264
Mailing Address - Country:US
Mailing Address - Phone:417-761-5000
Mailing Address - Fax:417-761-5011
Practice Address - Street 1:1423 N JEFFERSON AVE STE D200
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802
Practice Address - Country:US
Practice Address - Phone:417-761-5820
Practice Address - Fax:417-761-5821
Is Sole Proprietor?:No
Enumeration Date:2017-06-09
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017041324101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490049724Medicaid