Healthcare Provider Details

I. General information

NPI: 1598961765
Provider Name (Legal Business Name): DIVINE DELIVERANCE COUNSELING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S BATES ST
WAYNESVILLE MO
65583-2146
US

IV. Provider business mailing address

100 S BATES ST
WAYNESVILLE MO
65583-2146
US

V. Phone/Fax

Practice location:
  • Phone: 573-774-5894
  • Fax: 573-774-6975
Mailing address:
  • Phone: 573-774-5894
  • Fax: 573-774-6975

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number002680
License Number StateMO

VIII. Authorized Official

Name: DR. CLIFTON JUNIOR RUGGS III
Title or Position: DIRECTOR
Credential: D.MIN., LPC, CASAC
Phone: 573-774-5894