Healthcare Provider Details

I. General information

NPI: 1679099725
Provider Name (Legal Business Name): EMBARK BY CALO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2017
Last Update Date: 08/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 CROSSING DRIVE SUITE 1
LAKE OZARK MO
65049
US

IV. Provider business mailing address

P.O. BOX 1810
LAKE OZARK MO
65049
US

V. Phone/Fax

Practice location:
  • Phone: 573-365-2221
  • Fax:
Mailing address:
  • Phone: 573-365-2221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2012040525
License Number StateMO

VIII. Authorized Official

Name: CECILY M MITCHELL
Title or Position: DIRECTOR
Credential:
Phone: 913-593-6376