Healthcare Provider Details

I. General information

NPI: 1790255784
Provider Name (Legal Business Name): RE-ENTRY TRANSITIONS COUNSELING, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2018
Last Update Date: 03/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 MARKET ST STE 101
FULTON MO
65251-2808
US

IV. Provider business mailing address

500 MARKET ST STE 101
FULTON MO
65251-2808
US

V. Phone/Fax

Practice location:
  • Phone: 573-246-6000
  • Fax:
Mailing address:
  • Phone: 573-246-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MS. DEBRA MADDOX LAURIE
Title or Position: OWNER/ SOLE MEMBER
Credential: M.ED., LCSW
Phone: 573-246-6000