Healthcare Provider Details

I. General information

NPI: 1669856068
Provider Name (Legal Business Name): BRANDON BECK CARROLL PLP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2015
Last Update Date: 10/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 N MAIN ST
WINDSOR MO
65360-1449
US

IV. Provider business mailing address

1800 COMMUNITY
CLINTON MO
64735-8804
US

V. Phone/Fax

Practice location:
  • Phone: 888-403-1071
  • Fax: 660-647-3617
Mailing address:
  • Phone: 660-885-8131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number2019039855
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: