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General NPI Number Information
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NPI Number | 1679099725
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Entity Type | Organization
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Legal Business Name | EMBARK BY CALO
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Dates
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Enumeration Date | 08/21/2017
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Last Update Date | 08/21/2017
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Provider Practice Location Address
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Address Line | 110 CROSSING DRIVE SUITE 1
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City | LAKE OZARK
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State | MO
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Zip | 65049
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Country | US
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Telephone | 573-365-2221
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Fax |
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Provider Business Mailing Address
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Address Line | P.O. BOX 1810
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City | LAKE OZARK
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State | MO
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Zip | 65049
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Country | US
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Telephone | 573-365-2221
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | CECILY M MITCHELL
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Credential |
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Telephone | 913-593-6376
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 2012040525
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License Number State | MO
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