Basic Information
Provider Information | |||||||||
NPI: | 1588757595 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ANDREW | ||||||||
FirstName: | TAMARA | ||||||||
MiddleName: | LEIGH | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS, LPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MILLER | ||||||||
OtherFirstName: | TAMARA | ||||||||
OtherMiddleName: | LEIGH | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2526 | ||||||||
Address2: |   | ||||||||
City: | JOPLIN | ||||||||
State: | MO | ||||||||
PostalCode: | 648032526 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4173477580 | ||||||||
FaxNumber: | 4173477629 | ||||||||
Practice Location | |||||||||
Address1: | 1800 W 30TH ST | ||||||||
Address2: |   | ||||||||
City: | JOPLIN | ||||||||
State: | MO | ||||||||
PostalCode: | 648041520 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4713477580 | ||||||||
FaxNumber: | 4713477582 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/02/2006 | ||||||||
LastUpdateDate: | 01/30/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 2004012498 | MO | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
ID | Type | State | Issuer | Description | 498774413 | 05 | MO |   | MEDICAID |