Healthcare Provider Details

I. General information

NPI: 1063280899
Provider Name (Legal Business Name): EAGLES WINGS COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2023
Last Update Date: 12/12/2023
Certification Date: 12/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3322 S CAMPBELL AVE
SPRINGFIELD MO
65807-4980
US

IV. Provider business mailing address

804 S NATALIE AVE
SPRINGFIELD MO
65802-9702
US

V. Phone/Fax

Practice location:
  • Phone: 417-207-9039
  • Fax: 855-425-0096
Mailing address:
  • Phone: 417-207-9039
  • Fax: 855-425-0096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: JESIKA GOMEZ
Title or Position: OWNER
Credential:
Phone: 417-207-9039