Healthcare Provider Details

I. General information

NPI: 1699166322
Provider Name (Legal Business Name): BENNIE SPURLOCK LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2015
Last Update Date: 02/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 SW 13TH ST
LEES SUMMIT MO
64081-3800
US

IV. Provider business mailing address

2900 SW 13TH ST
LEES SUMMIT MO
64081-3800
US

V. Phone/Fax

Practice location:
  • Phone: 816-516-7114
  • Fax: 816-761-1899
Mailing address:
  • Phone:
  • Fax: 816-761-1899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2001004516
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: