Provider Demographics
NPI:1487755187
Name:WHISMAN, KEVIN MICHAEL (PSYD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:MICHAEL
Last Name:WHISMAN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1027 S MAIN ST
Mailing Address - Street 2:SUITE 308
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64801-4527
Mailing Address - Country:US
Mailing Address - Phone:417-385-3491
Mailing Address - Fax:417-429-2340
Practice Address - Street 1:1027 S MAIN ST
Practice Address - Street 2:SUITE 308
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-4527
Practice Address - Country:US
Practice Address - Phone:417-385-3491
Practice Address - Fax:417-429-2340
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000175013103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO495184715Medicaid
OK200078010AMedicaid
MO495184715Medicaid