Healthcare Provider Details

I. General information

NPI: 1073754768
Provider Name (Legal Business Name): WENDY SHALENE BLAYLOCK MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2009
Last Update Date: 03/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 E PACIFIC ST
KINGSVILLE MO
64061-2512
US

IV. Provider business mailing address

305 E PACIFIC
KINGSVILLE MO
64040
US

V. Phone/Fax

Practice location:
  • Phone: 816-597-3500
  • Fax:
Mailing address:
  • Phone: 816-597-3500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2006019504
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: