=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700148160
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREMIER THERAPIES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2012
-----------------------------------------------------
Last Update Date | 06/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2100 E. BROADWAY SUITE 206
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65201-6082
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-443-4038
-----------------------------------------------------
Fax | 573-657-1125
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2001 WINCHESTER DRIVE
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65202-3170
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-443-4038
-----------------------------------------------------
Fax | 573-657-1125
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. DIANE LA MAR
-----------------------------------------------------
Credential | L.P.C.
-----------------------------------------------------
Telephone | 573-443-4038
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 000750
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 000723
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 2004024724
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------