Healthcare Provider Details

I. General information

NPI: 1245952555
Provider Name (Legal Business Name): CYDNEY M CHURCHWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2022
Last Update Date: 08/24/2023
Certification Date: 08/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1627 W 26TH ST
JOPLIN MO
64804-0398
US

IV. Provider business mailing address

601 POOL RD
JOPLIN MO
64801-2158
US

V. Phone/Fax

Practice location:
  • Phone: 417-627-9601
  • Fax:
Mailing address:
  • Phone: 417-437-4139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2022009265
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: