1790837805 NPI number — MR. DOUGLAS EDWARD SPROUSE MASTERS IN SOCIAL WO

Table of content: MR. DOUGLAS EDWARD SPROUSE MASTERS IN SOCIAL WO (NPI 1790837805)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790837805 NPI number — MR. DOUGLAS EDWARD SPROUSE MASTERS IN SOCIAL WO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPROUSE
Provider First Name:
DOUGLAS
Provider Middle Name:
EDWARD
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MASTERS IN SOCIAL WO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790837805
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3805 OAKLAND AVENUE
Provider Second Line Business Mailing Address:
SUITE 102F
Provider Business Mailing Address City Name:
SAINT JOSEPH
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64506
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-671-9604
Provider Business Mailing Address Fax Number:
816-364-2158

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3805 OAKLAND AVENUE
Provider Second Line Business Practice Location Address:
SUITE 102F
Provider Business Practice Location Address City Name:
SAINT JOSEPH
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-671-9604
Provider Business Practice Location Address Fax Number:
816-364-2158
Provider Enumeration Date:
01/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  365 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 1041C0700X , with the licence number: 001033 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 19706028 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".




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