MEDICARE: SUPERNOVA COUNSELING SERVICES 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

General Provider Information

NPI Number	:	1467318642
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUPERNOVA COUNSELING SERVICES LLC

Provider Business Mailing Address
First Line	:	1133 W MAIN ST STE 101
Second Line	:
City	:	BLUE SPRINGS
State	:	MO
Zip	:	64015-3648
Country	:	US
Telephone Number	:	816-200-2753
Fax Number	:

Provider Business Practice Location Address
First Line	:	1133 W MAIN ST STE 101
Second Line	:
City	:	BLUE SPRINGS
State	:	MO
Zip	:	64015-3648
Country	:	US
Telephone Number	:	816-200-2753
Fax Number	:

Authorized Official
Title or Position	:	THERAPIST
Name	:	SHALEESE EUGENIA ROCKETT
Credential	:	LCSW
Telephone Number	:	816-853-5708

Provider Enumeration Date	:	12/31/2025
Last Update Date	:	12/31/2025

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Directions to “SUPERNOVA COUNSELING SERVICES LLC ” Practice Location

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