=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528942125
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALEXSANDRA RIDDLE
-----------------------------------------------------
Gender |
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2025
-----------------------------------------------------
Last Update Date | 08/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11016 E STATE HIGHWAY 76
-----------------------------------------------------
City | BRANSON WEST
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65737-9775
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-527-8877
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3554 W MADISON ST
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65802-5745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-818-6835
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 2025030777
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------