Healthcare Provider Details

I. General information

NPI: 1750586103
Provider Name (Legal Business Name): WHITE OAK COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2007
Last Update Date: 06/30/2021
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 BROADWAY
HANNIBAL MO
63401-4005
US

IV. Provider business mailing address

10299 TANGLEWOOD LN
HANNIBAL MO
63401-7453
US

V. Phone/Fax

Practice location:
  • Phone: 573-221-2111
  • Fax: 573-221-2123
Mailing address:
  • Phone: 573-221-2111
  • Fax: 573-221-2123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2004013377
License Number StateMO

VII. Legacy identifiers

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

# 1
Identifier491318625
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name: MRS. CARRIE DANNER
Title or Position: OWNER
Credential: MSW, LCSW
Phone: 573-221-2111