Healthcare Provider Details

I. General information

NPI: 1033968268
Provider Name (Legal Business Name): RADIANT ALLY THERAPY & CONSULTING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2024
Last Update Date: 10/27/2024
Certification Date: 10/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1911 S NATIONAL AVE STE 401
SPRINGFIELD MO
65804-2213
US

IV. Provider business mailing address

4195 E SUMMER SET ST
SPRINGFIELD MO
65802-9776
US

V. Phone/Fax

Practice location:
  • Phone: 417-719-0973
  • Fax:
Mailing address:
  • Phone: 417-719-0973
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. RA YOUNG SUH
Title or Position: THERAPIST
Credential: LCSW
Phone: 417-719-0973