Basic Information
| Provider Information | |||||||||
| NPI: | 1962737734 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FARNAN | ||||||||
| FirstName: | SHELLY | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSYD., LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 E BRADFORD PKWY | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658044264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4177615000 | ||||||||
| FaxNumber: | 4177615065 | ||||||||
| Practice Location | |||||||||
| Address1: | 1300 E BRADFORD PKWY | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4177615000 | ||||||||
| FaxNumber: | 4177615011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2009 | ||||||||
| LastUpdateDate: | 07/28/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 07/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 2009030819 | MO | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 499446706 | 05 | MO | MEDICAID |