Healthcare Provider Details

I. General information

NPI: 1306379482
Provider Name (Legal Business Name): MINERAL AREA PSYCHIATRIC SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2017
Last Update Date: 12/29/2024
Certification Date: 12/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 S WASHINGTON ST
FARMINGTON MO
63640-1836
US

IV. Provider business mailing address

203 S WASHINGTON ST
FARMINGTON MO
63640-1836
US

V. Phone/Fax

Practice location:
  • Phone: 573-664-1047
  • Fax:
Mailing address:
  • Phone: 573-664-1047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. GABRIEL E CRAWFORD
Title or Position: PMHNP
Credential: PMHNP-BC
Phone: 573-330-6468