Healthcare Provider Details

I. General information

NPI: 1740290063
Provider Name (Legal Business Name): CARL STANLEY MARR PSYCHOLOGIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 NE INDEPENDENCE AVE
LEES SUMMIT MO
64086-5544
US

IV. Provider business mailing address

3524 NE LACEWOOD CIR
LEES SUMMIT MO
64064-1853
US

V. Phone/Fax

Practice location:
  • Phone: 816-347-3286
  • Fax: 816-246-8207
Mailing address:
  • Phone: 816-478-6111
  • Fax: 816-246-8207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1108
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: