Healthcare Provider Details

I. General information

NPI: 1407775331
Provider Name (Legal Business Name): KENDRA NICHOLSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 E REPUBLIC RD STE D
SPRINGFIELD MO
65804-6588
US

IV. Provider business mailing address

1717 E REPUBLIC RD STE D
SPRINGFIELD MO
65804-6588
US

V. Phone/Fax

Practice location:
  • Phone: 417-351-4282
  • Fax: 844-683-2342
Mailing address:
  • Phone: 417-351-4282
  • Fax: 844-683-2342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2026021915
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: