Basic Information
Provider Information | |||||||||
NPI: | 1437294816 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FAMILY COUNSELING CENTER OF MISSOURI INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CEDAR RIDGE TREATMENT CENTER | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 117 N GARTH AVE | ||||||||
Address2: |   | ||||||||
City: | COLUMBIA | ||||||||
State: | MO | ||||||||
PostalCode: | 652034103 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5734432204 | ||||||||
FaxNumber: | 5738756607 | ||||||||
Practice Location | |||||||||
Address1: | 1091 MIDWAY DR | ||||||||
Address2: |   | ||||||||
City: | LINN CREEK | ||||||||
State: | MO | ||||||||
PostalCode: | 650521687 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5733466758 | ||||||||
FaxNumber: | 5733460621 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/21/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TACKER | ||||||||
AuthorizedOfficialFirstName: | ALLEN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 5734432204 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PH.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X |   |   | Y |   | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |   |
ID Information
ID | Type | State | Issuer | Description | 1649269622 | 01 | MO | FCCMO BILLING NPI NUMBER | OTHER |