Healthcare Provider Details

I. General information

NPI: 1104864248
Provider Name (Legal Business Name): AMY LEANN GRAGG MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3737 S ELIZABETH ST SUITE 100
INDEPENDENCE MO
64057-1759
US

IV. Provider business mailing address

3737 S ELIZABETH ST SUITE 100
INDEPENDENCE MO
64057-1759
US

V. Phone/Fax

Practice location:
  • Phone: 816-373-7577
  • Fax: 816-373-9572
Mailing address:
  • Phone: 816-373-7577
  • Fax: 816-373-9572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2002021314
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2440
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: