Healthcare Provider Details

I. General information

NPI: 1154629467
Provider Name (Legal Business Name): CHARIS SUZANNE PASTOR LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2011
Last Update Date: 03/10/2011
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

3504 SE ADAMS DR
BLUE SPRINGS MO
64014-5458
US

V. Phone/Fax

Practice location:
  • Phone: 816-373-9240
  • Fax:
Mailing address:
  • Phone: 816-210-4881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2011004120
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: