Healthcare Provider Details

I. General information

NPI: 1861597650
Provider Name (Legal Business Name): GARY UNDERWOOD LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 BROADWAY
MARBLE HILL MO
63764
US

IV. Provider business mailing address

402 S SILVER SPRINGS RD
CAPE GIRARDEAU MO
63703-7536
US

V. Phone/Fax

Practice location:
  • Phone: 573-238-1127
  • Fax: 573-238-1171
Mailing address:
  • Phone: 573-334-1100
  • Fax: 573-334-8819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number000254
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: