Healthcare Provider Details

I. General information

NPI: 1922352012
Provider Name (Legal Business Name): SPRING GROVE COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2012
Last Update Date: 10/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 A OSCAR DRIVE
JEFFERSON CITY MO
65101-5167
US

IV. Provider business mailing address

211 A OSCAR DRIVE
JEFFERSON CITY MO
65101-5167
US

V. Phone/Fax

Practice location:
  • Phone: 573-635-8299
  • Fax: 573-635-4629
Mailing address:
  • Phone: 573-635-8299
  • Fax: 573-635-4629

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number001621
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number002100
License Number StateMO

VIII. Authorized Official

Name: JUDY KAYE WIEBERG
Title or Position: OWNER/DIRECTOR
Credential: LPC, LCSW
Phone: 573-635-8299