Healthcare Provider Details

I. General information

NPI: 1568914927
Provider Name (Legal Business Name): CLEAR CREEK COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2016
Last Update Date: 11/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3646 N FARM ROAD 89
WILLARD MO
65781-8330
US

IV. Provider business mailing address

3646 NORTH FARM ROAD 89
WILLARD MO
65781
US

V. Phone/Fax

Practice location:
  • Phone: 573-619-8919
  • Fax:
Mailing address:
  • Phone: 417-850-4555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number2016035718
License Number StateMO

VIII. Authorized Official

Name: PEGGY LYNN THOENEN
Title or Position: COUNSELOR
Credential: PLPC
Phone: 573-619-8919