Basic Information
| Provider Information | |||||||||
| NPI: | 1811222573 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIRK | ||||||||
| FirstName: | LANDON | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | MSW, LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 130 CALO LN | ||||||||
| Address2: | |||||||||
| City: | LAKE OZARK | ||||||||
| State: | MO | ||||||||
| PostalCode: | 650499208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733652221 | ||||||||
| FaxNumber: | 5733652224 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 CALO LN | ||||||||
| Address2: | |||||||||
| City: | LAKE OZARK | ||||||||
| State: | MO | ||||||||
| PostalCode: | 650499208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733652221 | ||||||||
| FaxNumber: | 5733652224 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2009 | ||||||||
| LastUpdateDate: | 10/13/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 2007006610 | MO | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.