Healthcare Provider Details

I. General information

NPI: 1265265581
Provider Name (Legal Business Name): ALICIA PRY CPHT, CHW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2024
Last Update Date: 08/22/2024
Certification Date: 08/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 W KEARNEY ST STE 116
SPRINGFIELD MO
65803-2055
US

IV. Provider business mailing address

1457 E LINDBERG ST
SPRINGFIELD MO
65804-2418
US

V. Phone/Fax

Practice location:
  • Phone: 417-865-1547
  • Fax: 417-862-2571
Mailing address:
  • Phone: 417-773-8997
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number2018012435
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number17294
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: