Healthcare Provider Details

I. General information

NPI: 1154412971
Provider Name (Legal Business Name): CYNTHIA ANNETTE ERDELJAC LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 E OHIO ST SUITE 13
CLINTON MO
64735-2371
US

IV. Provider business mailing address

PO BOX 746
CLINTON MO
64735-0746
US

V. Phone/Fax

Practice location:
  • Phone: 660-885-9100
  • Fax: 660-885-9116
Mailing address:
  • Phone: 660-885-9100
  • Fax: 660-885-9116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2005015006
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: