Basic Information
| Provider Information | |||||||||
| NPI: | 1871960112 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLEVENGER | ||||||||
| FirstName: | MARION | ||||||||
| MiddleName: | STEPHEN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 223 JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | BONNE TERRE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 636281517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362887096 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1085 MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 636401955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737565353 | ||||||||
| FaxNumber: | 5737564557 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2015 | ||||||||
| LastUpdateDate: | 05/03/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 2015034337 | MO | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 2015034337 | 05 | MO | MEDICAID |