Healthcare Provider Details

I. General information

NPI: 1215532775
Provider Name (Legal Business Name): MISSOURI SOUTHERN STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2020
Last Update Date: 09/25/2023
Certification Date: 09/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3950 NEWMAN RD
JOPLIN MO
64801-1512
US

IV. Provider business mailing address

3950 NEWMAN RD
JOPLIN MO
64801-1512
US

V. Phone/Fax

Practice location:
  • Phone: 417-625-9600
  • Fax:
Mailing address:
  • Phone: 417-625-3078
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP0905X
TaxonomyState or Local Public Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AYLA SCHMICK
Title or Position: ACACIA CENTER DIRECTOR
Credential:
Phone: 175-625-3090