Healthcare Provider Details

I. General information

NPI: 1891087912
Provider Name (Legal Business Name): BRIAN FIDLER P.L.P.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2011
Last Update Date: 05/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 E 20TH ST
JOPLIN MO
64804-0928
US

IV. Provider business mailing address

1505 E 20TH ST
JOPLIN MO
64804-0928
US

V. Phone/Fax

Practice location:
  • Phone: 417-627-9601
  • Fax: 417-627-9032
Mailing address:
  • Phone: 417-627-9601
  • Fax: 417-627-9032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2010007554
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: