Healthcare Provider Details

I. General information

NPI: 1619710803
Provider Name (Legal Business Name): ALYSSA VONAGHER LMSW-T
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2024
Last Update Date: 06/14/2024
Certification Date: 06/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149 S ANDOVER RD STE 100
ANDOVER KS
67002-7935
US

IV. Provider business mailing address

149 S ANDOVER RD STE 100
ANDOVER KS
67002-7935
US

V. Phone/Fax

Practice location:
  • Phone: 316-247-3063
  • Fax: 316-247-6833
Mailing address:
  • Phone: 316-247-3063
  • Fax: 316-247-6833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number13659
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: