Healthcare Provider Details

I. General information

NPI: 1538365614
Provider Name (Legal Business Name): SAC RIVER COUNSELING, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2007
Last Update Date: 10/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 COLLEGE ST #2
GREENFIELD MO
65661-1346
US

IV. Provider business mailing address

928 E DADE 68
DADEVILLE MO
65635-8112
US

V. Phone/Fax

Practice location:
  • Phone: 417-637-1476
  • Fax:
Mailing address:
  • Phone: 417-777-1476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2004037100
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number2007003463
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2006033497
License Number StateMO

VIII. Authorized Official

Name: DR. REBECCA MARIE ROLLER
Title or Position: PRESIDENT
Credential: PSY.D.
Phone: 417-777-1476