Healthcare Provider Details

I. General information

NPI: 1730449901
Provider Name (Legal Business Name): TYNES AND ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2012
Last Update Date: 06/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 S WAVERLY AVE STE 700
SPRINGFIELD MO
65804-2400
US

IV. Provider business mailing address

2021 S WAVERLY AVE STE 700
SPRINGFIELD MO
65804-2400
US

V. Phone/Fax

Practice location:
  • Phone: 417-883-2725
  • Fax: 417-883-5653
Mailing address:
  • Phone: 417-883-2725
  • Fax: 417-883-5653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number000420
License Number StateMO

VII. Legacy identifiers

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

# 1
IdentifierMA3382
Identifier TypeOTHER
Identifier StateMO
Identifier IssuerMEDICARE PTAN

VIII. Authorized Official

Name: MS. KATHERINE M TYNES
Title or Position: OWNER
Credential: LCSW
Phone: 417-883-2725