Healthcare Provider Details

I. General information

NPI: 1699290627
Provider Name (Legal Business Name): MICHELLE RENEE MANUEL-TERRY MA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE RENEE MANUEL

II. Dates (important events)

Enumeration Date: 08/10/2017
Last Update Date: 10/18/2024
Certification Date: 10/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 OLD SOUTH RIVER RD
SAINT CHARLES MO
63303-4120
US

IV. Provider business mailing address

900 E LAHARPE ST
KIRKSVILLE MO
63501-4520
US

V. Phone/Fax

Practice location:
  • Phone: 636-224-1202
  • Fax: 636-946-0971
Mailing address:
  • Phone: 660-665-1962
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2017040813
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: