MEDICARE: SUNRISE COUNSELING LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	2004006930	MO

General Provider Information

NPI Number	:	1093090508
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUNRISE COUNSELING LLC

Provider Business Mailing Address
First Line	:	PO BOX 329
Second Line	:
City	:	HOLTS SUMMIT
State	:	MO
Zip	:	65043-0329
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1808A SOUTHWEST BLVD
Second Line	:
City	:	JEFFERSON CITY
State	:	MO
Zip	:	65109-2438
Country	:	US
Telephone Number	:	573-619-9387
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. JEANINE TAYLOR
Credential	:	LCSW
Telephone Number	:	573-619-9387

Provider Enumeration Date	:	10/15/2011
Last Update Date	:	11/19/2013

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