MEDICARE: MIDWEST NEUROPSYCHOLOGY AND BEHAVIORAL HEALTH, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	2013020719	MO
2	1041C0700X	Clinical Social Worker	2013015422	MO
3	103G00000X	Clinical Neuropsychologist	2013020719	MO

General Provider Information

NPI Number	:	1669805826
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDWEST NEUROPSYCHOLOGY AND BEHAVIORAL HEALTH, LLC

Provider Business Mailing Address
First Line	:	1864 S KENTWOOD AVE
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65804-2323
Country	:	US
Telephone Number	:	417-880-6838
Fax Number	:	417-374-0074

Provider Business Practice Location Address
First Line	:	1864 S KENTWOOD AVE
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65804-2323
Country	:	US
Telephone Number	:	417-880-6838
Fax Number	:	417-374-0074

Authorized Official
Title or Position	:	NEUROPSYCHOLOGIST
Name	:	DR. RYAN GRANT JONES
Credential	:	PSY.D.
Telephone Number	:	417-880-6838

Provider Enumeration Date	:	08/12/2013
Last Update Date	:	05/24/2021

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