Provider Demographics
NPI:1316458441
Name:PSYCH ASSOCIATES LLC
Entity type:Organization
Organization Name:PSYCH ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GABRIEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:CLINE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:417-414-0333
Mailing Address - Street 1:1358 E KINGSLEY ST STE E
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-7245
Mailing Address - Country:US
Mailing Address - Phone:417-414-0333
Mailing Address - Fax:417-268-9114
Practice Address - Street 1:1358 E KINGSLEY ST STE E
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804
Practice Address - Country:US
Practice Address - Phone:417-414-0333
Practice Address - Fax:417-268-9114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-16
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010006114103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth ServiceGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1558555045Medicaid