Healthcare Provider Details

I. General information

NPI: 1114918661
Provider Name (Legal Business Name): JOHN R GRAUE II M.S. AND TH.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 07/08/2007
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: 471-627-9032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number01724
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: