Provider Demographics
NPI:1902251960
Name:WITHERSPOON, ANGELA
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:WITHERSPOON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:723 E 18TH ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64108-1511
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:723 E 18TH ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64108-1511
Practice Address - Country:US
Practice Address - Phone:816-283-3877
Practice Address - Fax:816-283-3310
Is Sole Proprietor?:No
Enumeration Date:2016-04-27
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO8883101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)