Healthcare Provider Details

I. General information

NPI: 1336197854
Provider Name (Legal Business Name): WHOLE AND BALANCED THERAPY SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 02/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1459 E BROADWAY ST
BOLIVAR MO
65613-2950
US

IV. Provider business mailing address

PO BOX 347
BOLIVAR MO
65613-0347
US

V. Phone/Fax

Practice location:
  • Phone: 417-777-5314
  • Fax: 417-777-5320
Mailing address:
  • Phone: 417-777-5314
  • Fax: 417-777-5320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number2005038008
License Number StateMO

VIII. Authorized Official

Name: DR. DEBRA ANN ANDERSON
Title or Position: OWNER
Credential: PSY.D.
Phone: 417-777-5314