Basic Information
| Provider Information | |||||||||
| NPI: | 1306165535 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY COUNSELING CENTER OF MISSOURI INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117 N GARTH AVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652034103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734432204 | ||||||||
| FaxNumber: | 5738758581 | ||||||||
| Practice Location | |||||||||
| Address1: | 117 N GARTH AVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652034103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734432204 | ||||||||
| FaxNumber: | 5738758581 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2010 | ||||||||
| LastUpdateDate: | 05/27/2010 | ||||||||
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| AuthorizedOfficialLastName: | TACKET | ||||||||
| AuthorizedOfficialFirstName: | ALLEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 5734432204 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | 22222222 | 01 | MO | CSTARDOC COP BUL FAY | OTHER |