=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376857375
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WALTER VINCENT WINN MA, LPC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2010
-----------------------------------------------------
Last Update Date | 11/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3401 BERRYWOOD DR
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65201-8372
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-777-7530
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1300 E BRADFORD PKWY
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65804-4264
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-269-5400
-----------------------------------------------------
Fax | 417-269-7212
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 2000146843
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------