Basic Information
| Provider Information | |||||||||
| NPI: | 1962143081 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCONNELL | ||||||||
| FirstName: | EVAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1800 COMMUNITY | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 647358804 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 616 BURKARTH RD | ||||||||
| Address2: | |||||||||
| City: | WARRENSBURG | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640931462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8448538937 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2022 | ||||||||
| LastUpdateDate: | 04/05/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 2022011230 | MO | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.