Healthcare Provider Details

I. General information

NPI: 1508837857
Provider Name (Legal Business Name): BETSY HACKER WAHL M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

158 N ADAMS AVE SUITE 12
LEBANON MO
65536-3021
US

IV. Provider business mailing address

23175 PARADISE DR
LEBANON MO
65536-5146
US

V. Phone/Fax

Practice location:
  • Phone: 417-588-2933
  • Fax: 417-588-2375
Mailing address:
  • Phone: 417-532-5987
  • Fax: 417-588-2375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number000080
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: