Basic Information
Provider Information | |||||||||
NPI: | 1972197838 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HENAULT | ||||||||
FirstName: | ALEXA | ||||||||
MiddleName: | LAURA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 758 | ||||||||
Address2: |   | ||||||||
City: | NEOSHO | ||||||||
State: | MO | ||||||||
PostalCode: | 648500758 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4174519450 | ||||||||
FaxNumber: | 4174518903 | ||||||||
Practice Location | |||||||||
Address1: | 530 S MAIDEN LN | ||||||||
Address2: |   | ||||||||
City: | JOPLIN | ||||||||
State: | MO | ||||||||
PostalCode: | 648013084 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4177826200 | ||||||||
FaxNumber: | 4177826210 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/22/2021 | ||||||||
LastUpdateDate: | 02/22/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/19/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 2021005783 | MO | Y |   | Behavioral Health & Social Service Providers | Social Worker |   |
No ID Information.