Healthcare Provider Details

I. General information

NPI: 1235729575
Provider Name (Legal Business Name): AQUALUS MONDRELL GORDON PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2021
Last Update Date: 01/20/2021
Certification Date: 01/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 NE WINDSOR DR
LEES SUMMIT MO
64086-8477
US

IV. Provider business mailing address

702 NE WESTWIND DR
LEES SUMMIT MO
64086-5620
US

V. Phone/Fax

Practice location:
  • Phone: 816-287-8959
  • Fax:
Mailing address:
  • Phone: 512-923-5328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number2020017925
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2020017925
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: