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General NPI Number Information
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NPI Number | 1477156875
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Entity Type | Individual
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Provider Name | EVANGELINE SUPPES
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Gender | Female
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Dates
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Enumeration Date | 11/18/2020
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Last Update Date | 01/19/2025
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Provider Practice Location Address
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Address Line | 1339 S 20TH ST
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City | SAINT JOSEPH
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State | MO
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Zip | 64507-1246
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Country | US
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Telephone | 913-636-7932
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Fax |
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Provider Business Mailing Address
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Address Line | 1115 E PENCE RD
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City | CAMERON
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State | MO
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Zip | 64429-8804
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 2019045985
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 05276
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License Number State | KS
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