Basic Information
| Provider Information | |||||||||
| NPI: | 1891416426 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WORSTELL | ||||||||
| FirstName: | BREANNA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WATT | ||||||||
| OtherFirstName: | BREANNA | ||||||||
| OtherMiddleName: | R | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 2526 | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648032526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173477579 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1949 SNOWBERRY LN | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648045420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173477579 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2022 | ||||||||
| LastUpdateDate: | 09/12/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 2022033859 | MO | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.