=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386193654
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WISDOM THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2016
-----------------------------------------------------
Last Update Date | 09/28/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 N MAIN ST
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65560-1423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-739-1289
-----------------------------------------------------
Fax | 573-739-1165
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 419 COUNTY ROAD 734
-----------------------------------------------------
City | CENTERVILLE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63633-8309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-247-2025
-----------------------------------------------------
Fax | 573-689-1391
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR/LCSW
-----------------------------------------------------
Name | TASHA LYNN WISDOM
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 573-247-2025
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 2005024364
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 2014018308
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------