Healthcare Provider Details

I. General information

NPI: 1053986208
Provider Name (Legal Business Name): MISSOURI PSYCH SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2021
Last Update Date: 01/13/2022
Certification Date: 01/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2733 E BATTLEFIELD ST # 612
SPRINGFIELD MO
65804-3981
US

IV. Provider business mailing address

3593 MEDINA RD STE 181
MEDINA OH
44256-8182
US

V. Phone/Fax

Practice location:
  • Phone: 330-536-3746
  • Fax: 330-267-4250
Mailing address:
  • Phone: 330-536-3746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ROCCO CONIGLIO
Title or Position: CEO
Credential: CEO
Phone: 330-536-3746