Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TC1900X | Counseling Psychologist | 01724 | MO |
NPI | 1114918661 |
---|---|
Provider Name | John R Graue Ii |
First Address | Joplin, MO 64804-0928 |
Second Address | Joplin, MO 64804-0928 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/11/2005 |
Last Update Date | 08/07/2007 |