Basic Information
| Provider Information | |||||||||
| NPI: | 1679862445 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SPERA | ||||||||
| FirstName: | EDYTH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WOOLDRIDGE | ||||||||
| OtherFirstName: | EDYTH | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 2526 | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648032526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173477850 | ||||||||
| FaxNumber: | 4173477259 | ||||||||
| Practice Location | |||||||||
| Address1: | 2808 S PICHER AVE | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648041645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173477850 | ||||||||
| FaxNumber: | 4173477259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2011 | ||||||||
| LastUpdateDate: | 12/27/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 103K00000X | 2013044241 | MO | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.