Healthcare Provider Details

I. General information

NPI: 1659795946
Provider Name (Legal Business Name): LUCAS BRYAN PRYOR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2014
Last Update Date: 02/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7082 MADRID LN
NEOSHO MO
64850-6452
US

IV. Provider business mailing address

7082 MADRID LN
NEOSHO MO
64850-6452
US

V. Phone/Fax

Practice location:
  • Phone: 417-737-0275
  • Fax:
Mailing address:
  • Phone: 417-737-0275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: