Basic Information
| Provider Information | |||||||||
| NPI: | 1699151225 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COMP | ||||||||
| FirstName: | JOSHUA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MSW, LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3500 S NATIONAL AVE APT 138 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4175699330 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1300 E BRADFORD PKWY | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658044264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4177615000 | ||||||||
| FaxNumber: | 4177615011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2015 | ||||||||
| LastUpdateDate: | 09/06/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 2017032173 | MO | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 490024018 | 05 | MO | MEDICAID |