Healthcare Provider Details

I. General information

NPI: 1346682994
Provider Name (Legal Business Name): BRIAN A FIDLER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2013
Last Update Date: 10/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 LITTLE BLUE PKWY SUITE 360
INDEPENDENCE MO
64057-8312
US

IV. Provider business mailing address

4200 LITTLE BLUE PKWY SUITE 360
INDEPENDENCE MO
64057-8312
US

V. Phone/Fax

Practice location:
  • Phone: 816-622-3171
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateMO

VIII. Authorized Official

Name: BRIAN FIDLER
Title or Position: PRESIDENT
Credential:
Phone: 816-622-3171