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General NPI Number Information
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NPI Number | 1700302353
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Entity Type | Organization
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Legal Business Name | SOUTHERN LIGHT COMMUNITY COUNSELING
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Dates
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Enumeration Date | 08/16/2017
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Last Update Date | 08/16/2017
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Provider Practice Location Address
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Address Line | 1901 WOMMACK AVE
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City | BOLIVAR
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State | MO
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Zip | 65613-3128
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Country | US
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Telephone | 417-850-4555
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Fax | 417-777-7017
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Provider Business Mailing Address
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Address Line | 707 S PEARL AVE
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City | JOPLIN
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State | MO
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Zip | 64801-4334
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Country | US
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Telephone | 417-850-4555
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Fax | 417-777-7017
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Authorized Official
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Title or Position | ADMINISTRATIVE DIRECTOR
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Name | CINDY DRAKE
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Credential |
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Telephone | 417-850-4555
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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 |
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License Number State |
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