Healthcare Provider Details

I. General information

NPI: 1205293396
Provider Name (Legal Business Name): SHANE FRIEND
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2016
Last Update Date: 12/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2808 S PICHER AVE
JOPLIN MO
64804-1645
US

IV. Provider business mailing address

PO BOX 2526
JOPLIN MO
64803-2526
US

V. Phone/Fax

Practice location:
  • Phone: 417-347-7850
  • Fax:
Mailing address:
  • Phone: 417-347-7579
  • Fax: 417-347-0293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number2017037743
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: