Basic Information
| Provider Information | |||||||||
| NPI: | 1255609954 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KINZER | ||||||||
| FirstName: | LACEY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MS, LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | YORK-SHUMAKER | ||||||||
| OtherFirstName: | LACEY | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1300 E BRADFORD PKWY | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658044264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4177615000 | ||||||||
| FaxNumber: | 4177615065 | ||||||||
| Practice Location | |||||||||
| Address1: | 1300 E BRADFORD PKWY | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4177615000 | ||||||||
| FaxNumber: | 4177615011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2011 | ||||||||
| LastUpdateDate: | 08/07/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 2010029493 | MO | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101Y00000X | 2010029493 | MO | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 497116509 | 05 | MO | MEDICAID |