Provider Demographics
NPI:1720049471
Name:CLEVENGER, BRADY EVAN (MS PLPC)
Entity type:Individual
Prefix:MR
First Name:BRADY
Middle Name:EVAN
Last Name:CLEVENGER
Suffix:
Gender:M
Credentials:MS PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8225
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64802-8225
Mailing Address - Country:US
Mailing Address - Phone:417-624-4960
Mailing Address - Fax:
Practice Address - Street 1:2914 E 32ND ST
Practice Address - Street 2:SUITE 308
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-4402
Practice Address - Country:US
Practice Address - Phone:417-624-8333
Practice Address - Fax:417-624-0349
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005036369101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional