Provider Demographics
NPI:1174812275
Name:ALSUP, CONNIE JEAN (CRADAC)
Entity type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:JEAN
Last Name:ALSUP
Suffix:
Gender:F
Credentials:CRADAC
Other - Prefix:MRS
Other - First Name:CONNIE
Other - Middle Name:JEAN
Other - Last Name:BROOKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RASAC I
Mailing Address - Street 1:301 WARRIOR LANE
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63902
Mailing Address - Country:US
Mailing Address - Phone:573-686-1200
Mailing Address - Fax:573-686-1029
Practice Address - Street 1:301 WARRIOR LANE
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63902
Practice Address - Country:US
Practice Address - Phone:573-686-1200
Practice Address - Fax:573-686-1029
Is Sole Proprietor?:No
Enumeration Date:2011-03-30
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO4835101YA0400X
MO920101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)