Provider Demographics
NPI:1861581076
Name:BENDER, JOAN ELLEN (PHD)
Entity type:Individual
Prefix:DR
First Name:JOAN
Middle Name:ELLEN
Last Name:BENDER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 N JEFFERSON AVE
Mailing Address - Street 2:SUITE 221
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65806-1108
Mailing Address - Country:US
Mailing Address - Phone:417-862-0021
Mailing Address - Fax:417-862-0021
Practice Address - Street 1:309 N JEFFERSON AVE
Practice Address - Street 2:SUITE 221
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65806-1108
Practice Address - Country:US
Practice Address - Phone:417-862-0021
Practice Address - Fax:417-862-0021
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01160103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO496957903Medicaid
MO496957903Medicaid