Healthcare Provider Details

I. General information

NPI: 1952836645
Provider Name (Legal Business Name): CENTRAL METHODIST UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2017
Last Update Date: 05/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 CENTRAL METHODIST SQ RM 206
FAYETTE MO
65248-1104
US

IV. Provider business mailing address

5050 SPRING VALLEY RD
DALLAS TX
75244-3995
US

V. Phone/Fax

Practice location:
  • Phone: 972-367-4845
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number2005041421
License Number StateMS

VIII. Authorized Official

Name: MOUZON BASS III
Title or Position: AGENT
Credential:
Phone: 972-367-4845