Healthcare Provider Details

I. General information

NPI: 1093347965
Provider Name (Legal Business Name): T-K RANCH EQUINE ASSISTED COACHING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2020
Last Update Date: 02/10/2020
Certification Date: 02/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17885 HART PINKSTON RD
FARMINGTON MO
63640
US

IV. Provider business mailing address

17885 HART PINKSTON RD
FARMINGTON MO
63640
US

V. Phone/Fax

Practice location:
  • Phone: 573-747-9115
  • Fax: 855-209-5615
Mailing address:
  • Phone: 573-747-9115
  • Fax: 855-209-5615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: STACEY GILLETTE
Title or Position: THERAPIST/OWNER
Credential: LCSW
Phone: 573-747-9115