=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497216071
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AUTHENTIC TALK
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2019
-----------------------------------------------------
Last Update Date | 01/25/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 721 MAIN ST
-----------------------------------------------------
City | GRANDVIEW
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64030-2328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-368-1288
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14806 PINE VIEW DR
-----------------------------------------------------
City | GRANDVIEW
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64030-4573
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-588-5090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THERAPIST
-----------------------------------------------------
Name | MELISSA R VAUGHNS
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 816-368-1288
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------