Healthcare Provider Details

I. General information

NPI: 1629797030
Provider Name (Legal Business Name): NANCY MAYES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2022
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 WHITNEY LN
ROLLA MO
65401-3633
US

IV. Provider business mailing address

604 WHITNEY LN
ROLLA MO
65401-3633
US

V. Phone/Fax

Practice location:
  • Phone: 719-491-6595
  • Fax:
Mailing address:
  • Phone: 719-491-6595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberMHC-1192-0
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number2026003724
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number37PC01190600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: