Healthcare Provider Details

I. General information

NPI: 1649385469
Provider Name (Legal Business Name): JOHN PATRICK CHERVENAK M.R.C., C.R.C., L.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 GREENWOOD DR # B
POPLAR BLUFF MO
63901-2430
US

IV. Provider business mailing address

1631 SEIFERT DR
POPLAR BLUFF MO
63901-2555
US

V. Phone/Fax

Practice location:
  • Phone: 573-778-0705
  • Fax: 573-778-0925
Mailing address:
  • Phone: 573-686-6453
  • Fax: 573-686-6504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2004011118
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: