Healthcare Provider Details

I. General information

NPI: 1447231808
Provider Name (Legal Business Name): TABLE ROCK COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 05/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67 BISHOP LN
KIMBERLING CITY MO
65686-9818
US

IV. Provider business mailing address

67 BISHOP LN
KIMBERLING CITY MO
65686-9818
US

V. Phone/Fax

Practice location:
  • Phone: 417-230-1279
  • Fax: 417-739-1360
Mailing address:
  • Phone: 417-230-1279
  • Fax: 417-739-1360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberMO 004512
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberMO 004512
License Number StateMO

VIII. Authorized Official

Name: MS. LAURIE JEAN DOMSCH
Title or Position: LICENSED CLINICAL SOCIAL WORKER
Credential: ACSW, LCSW
Phone: 417-272-0055