Healthcare Provider Details

I. General information

NPI: 1467731018
Provider Name (Legal Business Name): THERESA ANNE GRIFFITH LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2011
Last Update Date: 11/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1059 BARTON DR
FORDLAND MO
65652-7350
US

IV. Provider business mailing address

414 BAILIWICK DR
ROGERSVILLE MO
65742-9750
US

V. Phone/Fax

Practice location:
  • Phone: 417-767-2273
  • Fax: 417-767-4054
Mailing address:
  • Phone: 417-718-0771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2011024836
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: