Basic Information
| Provider Information | |||||||||
| NPI: | 1265528921 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CALVERT | ||||||||
| FirstName: | ADRIENNE | ||||||||
| MiddleName: | ELOIS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SPEARS | ||||||||
| OtherFirstName: | ADRIENNE | ||||||||
| OtherMiddleName: | ELOIS | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 925 HWY VV | ||||||||
| Address2: | |||||||||
| City: | KENNETT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738885925 | ||||||||
| FaxNumber: | 5738889365 | ||||||||
| Practice Location | |||||||||
| Address1: | 925 HWY VV | ||||||||
| Address2: | |||||||||
| City: | KENNETT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738885925 | ||||||||
| FaxNumber: | 5738889365 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 09/04/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 497182709 | 05 | MO | MEDICAID | 918435 | 01 | HEALTHLINK HMO | OTHER | 1622156 | 01 | FIRST HEALTH/COVENTRY | OTHER | 918435 | 01 | HEALTHLINK PPO | OTHER | 11455956 | 01 | CAQH | OTHER | 2721 | 01 | EAP IMPACT | OTHER |