Basic Information
| Provider Information | |||||||||
| NPI: | 1417088220 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALDEMAN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | BETH | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 280 | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639020280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736861200 | ||||||||
| FaxNumber: | 5736861029 | ||||||||
| Practice Location | |||||||||
| Address1: | 3001 WARRIOR LN | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639018685 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736861200 | ||||||||
| FaxNumber: | 5736861029 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2007 | ||||||||
| LastUpdateDate: | 03/12/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 2007002228 | MO | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 11792021 | 01 | CAQH | OTHER | 2651 | 01 | EAP IMPACT | OTHER | 494914906 | 05 | MO | MEDICAID |