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General NPI Number Information
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NPI Number | 1245050186
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Entity Type | Organization
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Legal Business Name | TRIDENT COUNSELING CONSULTING & WELLNESS LLC
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Dates
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Enumeration Date | 10/15/2024
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Last Update Date | 10/15/2024
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Provider Practice Location Address
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Address Line | 112 W BROADWAY ST ST A
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City | BOLIVAR
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State | MO
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Zip | 61653
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Country | US
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Telephone | 417-631-3246
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Fax |
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Provider Business Mailing Address
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Address Line | 112 W BROADWAY ST ST A
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City | BOLIVAR
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State | MO
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Zip | 61653
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Country | US
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Telephone | 417-631-3246
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Fax |
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Authorized Official
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Title or Position | OWNER/PROVIDER
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Name | MELISSA DAVIS
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Credential | LCSW
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Telephone | 417-631-3246
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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