Healthcare Provider Details

I. General information

NPI: 1144375858
Provider Name (Legal Business Name): ELAINE ANN VIGNOLA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 12/22/2022
Certification Date: 12/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 N 2ND ST
CLINTON MO
64735-1192
US

IV. Provider business mailing address

104 S 3RD ST APT 3B
CLINTON MO
64735-2265
US

V. Phone/Fax

Practice location:
  • Phone: 660-885-5511
  • Fax:
Mailing address:
  • Phone: 660-351-0863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: