Healthcare Provider Details

I. General information

NPI: 1982240438
Provider Name (Legal Business Name): ALEXIS CALLIOPE NICOLE REDDIG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2019
Last Update Date: 11/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 E 5TH ST
FULTON MO
65251-1753
US

IV. Provider business mailing address

600 E 5TH ST
FULTON MO
65251-1753
US

V. Phone/Fax

Practice location:
  • Phone: 573-592-2605
  • Fax:
Mailing address:
  • Phone: 573-592-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number2019012780
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: