MEDICARE: FAITH TABERNACLE WORLD OUTREACH INC

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
2	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility	001742092	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417070210
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAITH TABERNACLE WORLD OUTREACH INC

Provider Business Mailing Address
First Line	:	PO BOX 25
Second Line	:
City	:	FREDRICKTOWN
State	:	MO
Zip	:	63645
Country	:	US
Telephone Number	:	573-783-4400
Fax Number	:	573-783-4409

Provider Business Practice Location Address
First Line	:	600 SARGENT DR
Second Line	:
City	:	FREDERICKTOWN
State	:	MO
Zip	:	63645-7526
Country	:	US
Telephone Number	:	573-783-4400
Fax Number	:	573-783-4409

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	MRS. DEBORAH JOY BOOTH
Credential	:	LPC
Telephone Number	:	573-783-4400

Provider Enumeration Date	:	04/08/2007
Last Update Date	:	10/15/2025

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Directions to “FAITH TABERNACLE WORLD OUTREACH INC ” Practice Location

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