Healthcare Provider Details

I. General information

NPI: 1851457840
Provider Name (Legal Business Name): BREAKTHROUGH COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 N. PINE STREET SUITE 101
ROLLA MO
65401-3181
US

IV. Provider business mailing address

901 N. PINE STREET SUITE 101
ROLLA MO
65401-3181
US

V. Phone/Fax

Practice location:
  • Phone: 573-426-2588
  • Fax: 573-426-4859
Mailing address:
  • Phone: 573-426-2588
  • Fax: 573-426-4859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number003819
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier$$$$$$$$$
Identifier TypeOTHER
Identifier StateMO
Identifier IssuerGARY EVANS SSN

VIII. Authorized Official

Name: DR. GARY T. EVANS
Title or Position: CLINICAL DIRECTOR
Credential: PHD
Phone: 573-426-2588