Basic Information
| Provider Information | |||||||||
| NPI: | 1760612212 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CULP | ||||||||
| FirstName: | EDDIE | ||||||||
| MiddleName: | KENNORD | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | M.A., CRC, CVE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2526 | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648032526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173477579 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1800 W 30TH ST | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648041520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173477580 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2009 | ||||||||
| LastUpdateDate: | 02/11/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | 00108835 | IL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 101YP2500X | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.