Healthcare Provider Details

I. General information

NPI: 1548009269
Provider Name (Legal Business Name): BOBBI SUE GREGORY CHW-C, CPHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2024
Last Update Date: 05/22/2024
Certification Date: 05/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

857 E MAIN ST STE 4
WILLOW SPRINGS MO
65793-1512
US

IV. Provider business mailing address

857 E MAIN ST STE 4
WILLOW SPRINGS MO
65793-1512
US

V. Phone/Fax

Practice location:
  • Phone: 417-855-1085
  • Fax:
Mailing address:
  • Phone: 417-855-1085
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number2009023719
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number520107010094402
License Number State
# 3
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number17745
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: