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General NPI Number Information
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NPI Number | 1568914927
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Entity Type | Organization
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Legal Business Name | CLEAR CREEK COUNSELING
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Dates
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Enumeration Date | 11/01/2016
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Last Update Date | 11/01/2016
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Provider Practice Location Address
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Address Line | 3646 N FARM ROAD 89
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City | WILLARD
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State | MO
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Zip | 65781-8330
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Country | US
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Telephone | 573-619-8919
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Fax |
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Provider Business Mailing Address
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Address Line | 3646 NORTH FARM ROAD 89
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City | WILLARD
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State | MO
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Zip | 65781
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Country | US
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Telephone | 417-850-4555
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Fax |
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Authorized Official
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Title or Position | COUNSELOR
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Name | PEGGY LYNN THOENEN
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Credential | PLPC
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Telephone | 573-619-8919
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 322D00000X
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Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
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License Number | 2016035718
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License Number State | MO
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