Healthcare Provider Details

I. General information

NPI: 1619616299
Provider Name (Legal Business Name): GREGORY J BACON MSW, LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2022
Last Update Date: 04/21/2023
Certification Date: 12/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1423 N JEFFERSON AVE
SPRINGFIELD MO
65802-1917
US

IV. Provider business mailing address

1300 E BRADFORD PKWY
SPRINGFIELD MO
65804-4264
US

V. Phone/Fax

Practice location:
  • Phone: 417-761-5000
  • Fax: 417-765-5011
Mailing address:
  • Phone: 417-761-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0000
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2022030684
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: