MEDICARE: DYNAMIC COUNSELING AND CONSULTATION SERVICES

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	2003032196	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

General Provider Information

NPI Number	:	1457771677
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DYNAMIC COUNSELING AND CONSULTATION SERVICES

Provider Business Mailing Address
First Line	:	1111 S LINCOLN AVE UNIT 1326
Second Line	:
City	:	O FALLON
State	:	IL
Zip	:	62269-5165
Country	:	US
Telephone Number	:	618-816-1224
Fax Number	:	800-335-4761

Provider Business Practice Location Address
First Line	:	4202 WILLIAMSON PL STE 1
Second Line	:
City	:	MOUNT VERNON
State	:	IL
Zip	:	62864-6760
Country	:	US
Telephone Number	:	618-816-1224
Fax Number	:	800-335-4761

Authorized Official
Title or Position	:	OWNER
Name	:	MS. CARRIE CROCKER
Credential	:	LCSW
Telephone Number	:	618-816-1224

Provider Enumeration Date	:	04/27/2014
Last Update Date	:	01/27/2025

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