Healthcare Provider Details

I. General information

NPI: 1467685271
Provider Name (Legal Business Name): BILLY JOE BERHORST M.S.W. L.C.S.W.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: BJ BERHORST M.S.W. L.C.S.W

II. Dates (important events)

Enumeration Date: 08/26/2009
Last Update Date: 08/29/2023
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 JAN MAR DR
CANTON MO
63435-1201
US

IV. Provider business mailing address

14 JAN MAR DR
CANTON MO
63435-1201
US

V. Phone/Fax

Practice location:
  • Phone: 217-430-9671
  • Fax:
Mailing address:
  • Phone: 174-309-6712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2006025160
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number007874
License Number StateIA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149011940
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: