Healthcare Provider Details

I. General information

NPI: 1952804668
Provider Name (Legal Business Name): EQUI-LIBRIUM THERAPY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2018
Last Update Date: 03/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1148 S COURTNEY LN
ROGERSVILLE MO
65742-4501
US

IV. Provider business mailing address

1148 S COURTNEY LN
ROGERSVILLE MO
65742-4501
US

V. Phone/Fax

Practice location:
  • Phone: 417-830-1409
  • Fax:
Mailing address:
  • Phone: 417-830-1409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QM1100X
TaxonomyMilitary/U.S. Coast Guard Outpatient Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ALEXIS R PUTTHOFF
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 417-830-1409