Healthcare Provider Details

I. General information

NPI: 1578057220
Provider Name (Legal Business Name): MERISSA PRYOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2018
Last Update Date: 11/21/2020
Certification Date: 11/20/2020
Deactivation Date: 07/31/2018
Reactivation Date: 10/10/2019

III. Provider practice location address

4200 CONESTOGA DRIVE, MBN 120
SPRINGFIELD IL
62711
US

IV. Provider business mailing address

4200 CONESTOGA DRIVE, MBN 120
SPRINGFIELD IL
62711
US

V. Phone/Fax

Practice location:
  • Phone: 217-220-5392
  • Fax:
Mailing address:
  • Phone: 217-220-5392
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.019250
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: