Basic Information
| Provider Information | |||||||||
| NPI: | 1699166322 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SPURLOCK | ||||||||
| FirstName: | BENNIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2900 SW 13TH ST | ||||||||
| Address2: | |||||||||
| City: | LEES SUMMIT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640813800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 8167611899 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 SW 13TH ST | ||||||||
| Address2: | |||||||||
| City: | LEES SUMMIT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640813800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8165167114 | ||||||||
| FaxNumber: | 8167611899 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2015 | ||||||||
| LastUpdateDate: | 02/17/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 2001004516 | MO | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.