Healthcare Provider Details

I. General information

NPI: 1386850204
Provider Name (Legal Business Name): SARAH ELISABETH BRESEKE M.A, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 W NIFONG BLVD BUILDING 5A
COLUMBIA MO
65203-6804
US

IV. Provider business mailing address

208 W BRANDON RD
COLUMBIA MO
65203-3574
US

V. Phone/Fax

Practice location:
  • Phone: 573-214-0436
  • Fax:
Mailing address:
  • Phone: 573-639-0112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2007002394
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: