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General NPI Number Information
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NPI Number | 1518547918
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Entity Type | Organization
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Legal Business Name | PETSBURGH THERAPY SERVICES LLC
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Dates
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Enumeration Date | 04/09/2021
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Last Update Date | 03/18/2024
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Provider Practice Location Address
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Address Line | 19871 SACKETT LN
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City | WAYNESVILLE
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State | MO
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Zip | 65583-3510
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Country | US
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Telephone | 573-315-3848
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Fax | 573-312-3848
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Provider Business Mailing Address
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Address Line | PO BOX 114
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City | ROBY
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State | MO
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Zip | 65557-0114
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Country | US
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Telephone | 573-315-3448
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Fax | 573-312-3848
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Authorized Official
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Title or Position | OWNER/TRAUMA SPECIALIST
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Name | CANDACE D BENNER
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Credential | MA, LPC, CCTP, EMDR
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Telephone | 573-315-3848
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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