Healthcare Provider Details

I. General information

NPI: 1336393669
Provider Name (Legal Business Name): PRAISE ASSEMBY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2008
Last Update Date: 11/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2032 E KEARNEY ST STE 214
SPRINGFIELD MO
65803-4662
US

IV. Provider business mailing address

4010 W HARRISON ST
SPRINGFIELD MO
65802-5756
US

V. Phone/Fax

Practice location:
  • Phone: 417-833-8300
  • Fax:
Mailing address:
  • Phone: 417-619-8921
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number2008032814
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number2008032814
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. TIM LYONS
Title or Position: LPC
Credential: MA.
Phone: 417-833-8300