Healthcare Provider Details

I. General information

NPI: 1306517990
Provider Name (Legal Business Name): SAMANTHA CHACE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2021
Last Update Date: 11/08/2021
Certification Date: 11/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W BROADWAY STE 2F
COLUMBIA MO
65203-3842
US

IV. Provider business mailing address

201 W BROADWAY STE 2F
COLUMBIA MO
65203-3842
US

V. Phone/Fax

Practice location:
  • Phone: 573-214-0436
  • Fax: 573-442-0606
Mailing address:
  • Phone: 573-214-0436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2021011989
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: