Healthcare Provider Details

I. General information

NPI: 1861880932
Provider Name (Legal Business Name): DENNIS BLUST LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/24/2014
Last Update Date: 12/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 W WORLEY ST
COLUMBIA MO
65203-2037
US

IV. Provider business mailing address

1001 W WORLEY ST
COLUMBIA MO
65203-2037
US

V. Phone/Fax

Practice location:
  • Phone: 573-214-2314
  • Fax: 573-814-2784
Mailing address:
  • Phone: 573-214-2314
  • Fax: 573-814-2784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2011040124
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: