Healthcare Provider Details

I. General information

NPI: 1245589258
Provider Name (Legal Business Name): MARION MATTHEW LYBARGER LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2012
Last Update Date: 09/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 W ASHLAND ST
NEVADA MO
64772-1710
US

IV. Provider business mailing address

1500 W ASHLAND ST
NEVADA MO
64772-1710
US

V. Phone/Fax

Practice location:
  • Phone: 417-667-2666
  • Fax: 417-448-5604
Mailing address:
  • Phone: 417-667-2666
  • Fax: 417-448-5604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number2012020860
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: