Healthcare Provider Details

I. General information

NPI: 1669805826
Provider Name (Legal Business Name): MIDWEST NEUROPSYCHOLOGY AND BEHAVIORAL HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2013
Last Update Date: 05/24/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1864 S KENTWOOD AVE
SPRINGFIELD MO
65804-2323
US

IV. Provider business mailing address

1864 S KENTWOOD AVE
SPRINGFIELD MO
65804-2323
US

V. Phone/Fax

Practice location:
  • Phone: 417-880-6838
  • Fax: 417-374-0074
Mailing address:
  • Phone: 417-880-6838
  • Fax: 417-374-0074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number2013020719
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2013020719
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2013015422
License Number StateMO

VIII. Authorized Official

Name: DR. RYAN GRANT JONES
Title or Position: NEUROPSYCHOLOGIST
Credential: PSY.D.
Phone: 417-880-6838