=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336197854
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WHOLE AND BALANCED THERAPY SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2006
-----------------------------------------------------
Last Update Date | 02/22/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1459 E BROADWAY ST
-----------------------------------------------------
City | BOLIVAR
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65613-2950
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-777-5314
-----------------------------------------------------
Fax | 417-777-5320
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 347
-----------------------------------------------------
City | BOLIVAR
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65613-0347
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-777-5314
-----------------------------------------------------
Fax | 417-777-5320
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DEBRA ANN ANDERSON
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 417-777-5314
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | 2005038008
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------