MEDICARE: MID-MISSOURI BLACK DOULA COLLECTIVE

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	374J00000X	Doula

General Provider Information

NPI Number	:	1407604762
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MID-MISSOURI BLACK DOULA COLLECTIVE

Provider Business Mailing Address
First Line	:	2801 S CABERNET CT
Second Line	:
City	:	COLUMBIA
State	:	MO
Zip	:	65201-8723
Country	:	US
Telephone Number	:	573-424-5485
Fax Number	:

Provider Business Practice Location Address
First Line	:	601 W BUSINESS LOOP 70 STE 214B
Second Line	:
City	:	COLUMBIA
State	:	MO
Zip	:	65203-2566
Country	:	US
Telephone Number	:	573-424-5485
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MS. ERICA ROCHELLE DICKSON
Credential	:
Telephone Number	:	573-424-5485

Provider Enumeration Date	:	05/10/2024
Last Update Date	:	05/10/2024

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