Basic Information
Provider Information | |||||||||
NPI: | 1538204904 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FAMILY COUNSELING CENTER OF MISSOURI, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BOONVILLE OUTPATIENT CLINIC | ||||||||
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: | 15899 LOGANS LAKE RD | ||||||||
Address2: | #A | ||||||||
City: | BOONVILLE | ||||||||
State: | MO | ||||||||
PostalCode: | 652332866 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6608822333 | ||||||||
FaxNumber: | 6608822333 | ||||||||
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 | 101Y00000X |   |   | X | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor |   | 261Q00000X |   |   | X |   | Ambulatory Health Care Facilities | Clinic/Center |   |
ID Information
ID | Type | State | Issuer | Description | 1649269622 | 01 | MO | FCCMO BILLING NPI NUMBER | OTHER |